L’avant-corps de la tour philippienne du château de Chinon (Indre-et-Loire) : un exemple d’adaptation d’un standard architectural aux contraintes topographiques

Le “ donjon du Coudray ” est une tour circulaire de type philippien dont le donjon n’est pas entièrement classique, puisque, contrairement aux autres érigés par les ingénieurs de Philippe Auguste, elle est desservie par un avant-corps rectangulaire donnant accès au premier étage. Sa fouille et l’étude fine de ses élévations ont permis de s’assurer que cet avant-corps atypique était bien contemporain de la tour. On a pu en reconstituer avec certitude les parties disparues. Plus qu’un archaïsme contredit par le soin apporté à l’édifice tout entier, les auteurs l’interprètent comme une réponse ponctuelle à une contrainte topographique.The Coudray keep is a circular tower of the Philippe Auguste type. The tower type is not entirely classic, since, as opposed to others erected by the engineers of Philippe Auguste, it is served by a rectangular projection which gives access to the first floor. The excavation and detailed study of its elevations have enabled us to ensure that the unusual projection was really comptemporary with the tower. It was possible to reconstruct its missing sections with certainty. More than just an archaism contradicted by the care given to the building as a whole, the creators construed it as a short term answer to a topographic constraint

L’avant-corps de la tour philippienne du château de Chinon (Indre-et-Loire) : un exemple d’adaptation d’un standard architectural aux contraintes topographiques

Le “ donjon du Coudray ” est une tour circulaire de type philippien dont le donjon n’est pas entièrement classique, puisque, contrairement aux autres érigés par les ingénieurs de Philippe Auguste, elle est desservie par un avant-corps rectangulaire donnant accès au premier étage. Sa fouille et l’étude fine de ses élévations ont permis de s’assurer que cet avant-corps atypique était bien contemporain de la tour. On a pu en reconstituer avec certitude les parties disparues. Plus qu’un archaïsme contredit par le soin apporté à l’édifice tout entier, les auteurs l’interprètent comme une réponse ponctuelle à une contrainte topographique.The Coudray keep is a circular tower of the Philippe Auguste type. The tower type is not entirely classic, since, as opposed to others erected by the engineers of Philippe Auguste, it is served by a rectangular projection which gives access to the first floor. The excavation and detailed study of its elevations have enabled us to ensure that the unusual projection was really comptemporary with the tower. It was possible to reconstruct its missing sections with certainty. More than just an archaism contradicted by the care given to the building as a whole, the creators construed it as a short term answer to a topographic constraint

Recommendations on the use of recombinant activated factor VII as an adjunctive treatment for massive bleeding – a European perspective

INTRODUCTION: Our aim was to develop consensus guidelines for use of recombinant activated factor VII (rFVIIa) in massive hemorrhage. METHODS: A guidelines committee derived the recommendations using clinical trial and case series data identified through searches of available databases. Guidelines were graded on a scale of A to E (with A being the highest) according to the strength of evidence available. Consensus was sought among the committee members for each recommendation. RESULTS: A recommendation for the use of rFVIIa in blunt trauma was made (grade B). rFVIIa might also be beneficial in post-partum hemorrhage (grade E), uncontrolled bleeding in surgical patients (grade E), and bleeding after cardiac surgery (grade D). rFVIIa could not be recommended for use in the following: in penetrating trauma (grade B); prophylactically in elective surgery (grade A) or liver surgery (grade B); or in bleeding episodes in patients with Child–Pugh A cirrhosis (grade B). Efficacy of rFVIIa was considered uncertain in bleeding episodes in patients with Child–Pugh B and C cirrhosis (grade C). Monitoring of rFVIIa efficacy should be performed visually and by assessment of transfusion requirements (grade E), while thromboembolic adverse events are a cause for concern. rFVIIa should not be administered to patients considered unsalvageable by the treating medical team. CONCLUSION: There is a rationale for using rFVIIa to treat massive bleeding in certain indications, but only adjunctively to the surgical control of bleeding once conventional therapies have failed. Lack of data from randomized, controlled clinical trials, and possible publication bias of the case series data, limits the strength of the recommendations that can be made

Determination of the threshold of cardiac troponin I associated with an adverse postoperative outcome after cardiac surgery: a comparative study between coronary artery bypass graft, valve surgery, and combined cardiac surgery

ABSTRACT: BACKGROUND: To compare postoperative cardiac troponin I (cTnI) release and the thresholds of cTnI that predict adverse outcome after elective coronary artery bypass graft (CABG), valve, and combined cardiac surgery. METHODS: Six hundred and seventy five adult patients undergoing conventional cardiac surgery with cardiopulmonary bypass were retrospectively analyzed. Patients in the CABG (n=225) and valve surgery groups (n=225) were selected after matching (age, sex) with those in the combined surgery group (n=225). cTnI was measured preoperatively and 24 h after the end of surgery. The main endpoint was a severe postoperative cardiac event (sustained ventricular arrhythmias requiring treatment, need for inotropic support or intra-aortic balloon pump for at least 24 h, postoperative myocardial infarction) and/or death. Data are medians and odds ratio [95% confidence interval]. RESULTS: Postoperative cTnI levels were significantly different among the three groups (Combined 11.0 [9.5-13.1] vs. CABG 5.2 [4.7-5.7] and Valve 7.8 [7.6-8.0] ng.mL-1, respectively, P<0.05). The thresholds of cTnI predicting severe cardiac event and/or death were also significantly different among the three groups (Combined 11.8 [11.5-14.8] vs. CABG 7.8 [6.7-8.8] and Valve 9.3 [8.0-14.0] ng.mL-1 respectively, P<0.05 level). An elevated cTnI above the threshold in each group was significantly associated with severe cardiac event and/or death (odds ratio, 4.33 [2.82-6.64]). CONCLUSIONS: The magnitude of postoperative cTnI release is related to the type of cardiac surgical procedure. Different thresholds of cTnI must be considered according to the procedure type to predict early an adverse postoperative outcom

Guideline-concordant administration of prothrombin complex concentrate and vitamin K is associated with decreased mortality in patients with severe bleeding under vitamin K antagonist treatment (EPAHK study).

International audienceINTRODUCTION: In vitamin K antagonist (VKA)-treated patients with severe hemorrhage, guidelines recommend prompt VKA reversal with prothrombin complex concentrate (PCC) and vitamin K. The aim of this observational cohort study was to evaluate the impact of guideline concordant administration of PCC and vitamin K on 7-day mortality. METHODS: Data from consecutive patients treated with PCC were prospectively collected in 44 emergency departments. Type of hemorrhage, coagulation parameters, type of treatment and 7-day mortality were recorded. Guideline-concordant administration of PCC and vitamin K (GC-PCC-K) were defined by at least 20 IU/kg factor IX equivalent PCC and at least 5 mg of vitamin K performed within a predefined time frame of 8 hours after admission. Multivariate analysis was used to assess the effect of appropriate reversal on 7-day mortality in all patients and in those with intracranial hemorrhage (ICH). RESULTS: Data from 822 VKA-treated patients with severe hemorrhage were collected over 14 months. Bleeding was gastrointestinal (32%), intracranial (32%), muscular (13%), and "other" (23%). In the whole cohort, 7-day mortality was 13% and 33% in patients with ICH. GC-PCC-K was performed in 38% of all patients and 44% of ICH patients. Multivariate analysis showed a two-fold decrease in 7-day mortality in patients with GC-PCC-K (odds ratio (OR) = 2.15 (1.20 to 3.88); P = 0.011); this mortality reduction was also observed when only ICH was considered (OR = 3.23 (1.53 to 6.79); P = 0.002). CONCLUSIONS: Guideline-concordant VKA reversal with PCC and vitamin K within 8 hours after admission was associated with a significant decrease in 7-day mortality

Cross-checking to reduce adverse events resulting from medical errors in the emergency department: study protocol of the CHARMED cluster randomized study

International audienceBackgroundMedical errors and preventable adverse events are a major cause of concern, especially in the emergency department (ED) where its prevalence has been reported to be roughly of 5–10 % of visits. Due to a short length of stay, emergency patients are often managed by a sole physician – in contrast with other specialties where they can benefit from multiples handover, ward rounds and staff meetings. As some studies report that the rate and severity of errors may decrease when there is more than one physician involved in the management in different settings, we sought to assess the impact of regular systematic cross-checkings between physicians in the ED.DesignThe CHARMED (Cross-checking to reduce adverse events resulting from medical errors in the emergency department) study is a multicenter cluster randomized study that aim to evaluate the reduction of the rate of severe medical errors with implementation of systematic cross checkings between emergency physician, compared to a control period with usual care. This study will evaluate the effect of this intervention on the rate of severe medical errors (i.e. preventable adverse events or near miss) using a previously described two-level chart abstraction. We made the hypothesis that implementing frequent and systematic cross checking will reduce the rate of severe medical errors from 10 to 6 % - 1584 patients will be included, 140 for each period in each center.DiscussionThe CHARMED study will be the largest study that analyse unselected ED charts for medical errors. This could provide evidence that frequent systematic cross-checking will reduce the incidence of severe medical errors

Does taking endurance into account improve the prediction of weaning outcome in mechanically ventilated children?

INTRODUCTION: We conducted the present study to determine whether a combination of the mechanical ventilation weaning predictors proposed by the collective Task Force of the American College of Chest Physicians (TF) and weaning endurance indices enhance prediction of weaning success. METHOD: Conducted in a tertiary paediatric intensive care unit at a university hospital, this prospective study included 54 children receiving mechanical ventilation (≥6 hours) who underwent 57 episodes of weaning. We calculated the indices proposed by the TF (spontaneous respiratory rate, paediatric rapid shallow breathing, rapid shallow breathing occlusion pressure [ROP] and maximal inspiratory pressure during an occlusion test [Pi(max)]) and weaning endurance indices (pressure-time index, tension-time index obtained from P(0.1 )[TTI(1)] and from airway pressure [TTI(2)]) during spontaneous breathing. Performances of each TF index and combinations of them were calculated, and the best single index and combination were identified. Weaning endurance parameters (TTI(1 )and TTI(2)) were calculated and the best index was determined using a logistic regression model. Regression coefficients were estimated using the maximum likelihood ratio (LR) method. Hosmer–Lemeshow test was used to estimate goodness-of-fit of the model. An equation was constructed to predict weaning success. Finally, we calculated the performances of combinations of best TF indices and best endurance index. RESULTS: The best single TF index was ROP, the best TF combination was represented by the expression (0.66 × ROP) + (0.34 × Pi(max)), and the best endurance index was the TTI(2), although their performance was poor. The best model resulting from the combination of these indices was defined by the following expression: (0.6 × ROP) – (0.1 × Pi(max)) + (0.5 × TTI(2)). This integrated index was a good weaning predictor (P < 0.01), with a LR(+ )of 6.4 and LR(+)/LR(- )ratio of 12.5. However, at a threshold value <1.3 it was only predictive of weaning success (LR(- )= 0.5). CONCLUSION: The proposed combined index, incorporating endurance, was of modest value in predicting weaning outcome. This is the first report of the value of endurance parameters in predicting weaning success in children. Currently, clinical judgement associated with spontaneous breathing trials apparently remain superior