Du processus aux soins intégrés: Expérience de gestion de projet bottom-up

Le service de chirurgie cardiaque du CHU de Liège a soutenu des recherches visant à développer un programme d’épargne sanguine, enjeu actuel de taille dans ce secteur des soins de santé. Ce projet a évolué vers la création d’un itinéraire clinique chirurgical cardiaque et d’un modèle institutionnel pour le développement d’autres itinéraires cliniques. Une évolution qui permet de déterminer les missions spécifiques de l’institution et ses objectifs stratégiques, et de s’associer aux projets nationaux. L’adhésion multidisciplinaire, soutenue par un leadership médical et infirmier, ainsi que la reconnaissance institutionnelle sont les déterminants de la pérennité de cette démarche bottom-up

Impact of timing administration of mesenchymal stromal cells on serum creatinine following renal ischemia/ reperfusion in rats

peer reviewedExperimental models of renal ischemia/reperfusion (I/R) have suggested protective effects of mesenchymal stromal cells (MSC) therapy. Still, param- eters of MSC injection, including volume, route and timing of cell administration, remain largely debated. Particularly, MSC infusion in mouse has been shown to be beneficial “a priori” but deleterious “a posteriori” of renal I/R injury. In order to further investigate the influence of the timing of MSC administration, we used 10-week-old Lewis rats categorized in 4 groups. Groups 1 (MSC D-7, n = 10) and 2 (MSC D + 1, n = 7) received caudal i.v. injection of MSC (1.5 9 106 in 1 ml of saline) 7 days before or 1 day after renal I/R, respectively. Control groups 3 (saline D-7, n = 6) and 4 (saline D + 1, n = 6) received equal volume of saline at similar time points. Left renal ischemia (by clamping of the renal pedicle) lasted 45 min. Right nephrectomy was simultaneously performed. Blood sample was collected from inferior vena cava at 48 h post reperfusion. MSC phenotype was confirmed by FACS analysis. In groups 1 and 3, serum creatinine (SCr) reached 1.4 ` 0.7 versus 2.4 ` 0.8 mg/dl, respectively (p < 0.05). In groups 2 and 4, SCr was 4.9 ` 0.7 versus 3.3 ` 0.9 mg/dl, respectively (p < 0.001). Furthermore, SCr levels were statistically worse when MSC were administered after renal I/R in comparison to a priori infusion (p < 0.0001). In conclusion, MSC administration 7 days prior to renal I/R attenuates kidney injury in comparison to (i) saline infusion or (ii) MSC infusion 1 day after renal I/R. Conversely, on the basis of SCr levels, MSC therapy performed after renal I/R worsens kidney injury in rats

Saignements postopératoires et autotransfusion

Bleeding in the postoperative period of cardiac surgery is not rare. Mediastinal bleedings could potentially be saved with a cell salvage device. This practice may contribute to decreased allogeneic transfusion. This study explores the effectiveness of a chest drainage system combined with a cell salvage option during the postoperative period of cardiac surgery in patients at high risk of bleedingL'épargne sanguine à travers l'itinéraire clinique du patient opéré cardiaqu

Administration of Third-Party Mesenchymal Stromal Cells at the Time of Kidney Transplantation: Interim Safety Analysis at One-Year Follow-Up

Mesenchymal stromal cells (MSC)-based therapy has been proposed in kidney transplantation (KTx). We report on the 1-year follow-up of an open-label phase I trial using MSC in KTx. On postoperative day 3, third-party MSC (~2.0x106/kg) were administered to 7 non-immunized first-transplant recip- ients from deceased donors, under standard immunosuppression (Basiliximab, Tacrolimus, MMF and steroids). No HLA matching was required for MSC donors. Seven comparable KTx recipients were included as controls. Informed consent was obtained. No side-effect was noted at the time of MSC injection. Still, 1 patient with a history of ischemic heart disease had a NSTEMI ~3h after MSC infusion. Ten months after KTx, 1 MSC patient had type B aortic dissection and STEMI. Four MSC patients had at least 1 opportunistic infection, whereas 3 controls had polyoma-BK viremia. At day 14, eGFR in MSC and control groups was 47.1 ± 6.8 and 39.7 ± 5.9 ml/min, respectively (p, 0.05). At 1 year, eGFR in MSC and control groups was 46.5 ± 18.6 and 54.2 ± 16.3 ml/min, respectively (p, 0.42). Per-cause biopsies evidenced 1 bor- derline and 1 acute rejections in MSC group, whereas no AR was biopsy-proven in controls. Three patients developed anti-HLA antibodies against MSC (n=1) or shared kidney/MSC (n=2) mismatches.MSC infusion was safe in all patients except one. Incidence of opportunist infections was similar in both groups. No difference in eGFR was found at 1-year post KTx. Putative immunization against MSC was observed in 3 patients

Mesenchymal Stromal Cell Therapy in Ischemia/Reperfusion Injury.

Ischemia/reperfusion injury (IRI) represents a worldwide public health issue of increasing incidence. IRI may virtually affect all organs and tissues and is associated with significant morbidity and mortality. Particularly, the duration of blood supply deprivation has been recognized as a critical factor in stroke, hemorrhagic shock, or myocardial infarction, as well as in solid organ transplantation (SOT). Pathophysiologically, IRI causes multiple cellular and tissular metabolic and architectural changes. Furthermore, the reperfusion of ischemic tissues induces both local and systemic inflammation. In the particular field of SOT, IRI is an unavoidable event, which conditions both short- and long-term outcomes of graft function and survival. Clinically, the treatment of patients with IRI mostly relies on supportive maneuvers since no specific target-oriented therapy has been validated thus far. In the present review, we summarize the current literature on mesenchymal stromal cells (MSC) and their potential use as cell therapy in IRI. MSC have demonstrated immunomodulatory, anti-inflammatory, and tissue repair properties in rodent studies and in preliminary clinical trials, which may open novel avenues in the management of IRI and SOT

Role of AMP-activated protein kinase in renal ischemic preconditioning.

Kidney transplantation represents the best treatment of end-stage renal disease. In addition to the degree of human leukocyte antigen matching, long-term graft survival is influenced by the quality of the graft before its transplantation. Quality criteria include the level of ischemic damage caused by the transplantation per se. Renal ischemic preconditioning (IP) consists of different approaches to prevent ischemia/reperfusion (I/R) damage induced by the interruption and recovery of renal circulation, as observed during transplantation. Distinct animal models show promising results regarding the efficiency of PCI to preserve kidney structure and function in I/R conditions. Characterizing the cellular cascades involved in I/R led to the identification of putative targets of renal IP, including the adenosine monophosphate-activated protein kinase (AMPK). AMPK is a ubiquitous energy sensor, which has been implicated in the maintenance of epithelial cell polarization under energy deprivation. Among others, the anti-diabetic drug, metformin, is a potent activator of AMPK. Here, we summarize the in vitro and in vivo data about the role of AMPK in renal IP. Defining the pharmacological conditions of IP would help to improve the quality of the renal graft before its transplantation, thereby increasing its long-term survival.Peer reviewe

Du processus aux soins intégrés : expérience de gestion de projet bottom-up

Implementation of blood conservation strategies is a current issue in a public health view, especially in cardiac surgery. A service project has been initiated in the cardiovascular department of the CHU of Liege aiming to develop a blood conservation program. This project has evolved into the creation of a clinical pathway of the cardiac surgery patient and then into an institutional model for the development of other clinical pathways. This evolution leads to meet with the missions and strategic objectives of the Institution and some national projects. The process of this approach weaves a horizontal and vertical grid. The multidisciplinary membership, supported by medical and nursing leadership and the institutional support, will determine the sustainability of this project.L’épargne sanguine est actuellement un enjeu de taille dans le secteur des soins de santé, notamment en chirurgie cardiaque. Le service de chirurgie cardiaque du CHU de Liège a soutenu des recherches visant à développer un programme d’épargne sanguine. Ce projet a évolué vers la création d’un itinéraire clinique chirurgical cardiaque et d’un modèle institutionnel pour le développement d’autres itinéraires cliniques. Cette évolution permet au projet de déterminer les missions spécifiques de l’institution et ses objectifs stratégiques d’une part, et d’autre part, de s’associer aux projets nationaux. Le processus de cette démarche tisse un maillage horizontal et vertical. L’adhésion multidisciplinaire, soutenue par un leadership médical et infirmier, ainsi que la reconnaissance institutionnelle, sont les déterminants de sa pérennité

Estimation de la transparence de l'atmosphère par ciel clair à la Station Scientifique des Hautes-fagnes (SSHF), Mont Rigi, Belgique. Comparaison avec la Station d'Uccle-Bruxelles (IRM)

Cet article porte sur l’étude de la transparence de l’atmosphère par ciel clair au Mont Rigi (Hautes-Fagnes belges). Il a pour objectif la mise en évidence des particularités de la composition de l’air de cette région et la quantification de son influence sur le rayonnement solaire global. Nous avons utilisé les données suivantes: hauteur du Soleil, teneur en vapeur d’eau de l’air (caractérisée par la hauteur d’eau condensable) et rayonnement solaire reçu à la limite supérieure de l’atmosphère. En l’absence de données sur les particules en suspension dans l’air à la Station scientifique des Hautes-Fagnes (SSHF), nous avons comparé le rayonnement global reçu par ciel clair à celui enregistré pour de mêmes conditions et les mêmes journées à Uccle (Bruxelles), station de référence belge en matière de climatologie (Institut royal météorologique, IRM) et site urbain.This paper deals with the study of the transparency of the atmosphere on clear sky at the Mont Rigi (Belgian Hautes-Fagnes) with the aim of underlining the particularities of the air composition in the Hautes-Fagnes region and quantifying its influence on global solar radiation. We used the following data: solar elevation, water vapor content (characterized by atmospheric water depth) and solar extraterrestrial irradiation at the top of the atmosphere. Due to a lack of direct information about atmospheric pollution, we compared global radiation received at the Hautes-Fagnes scientific station (SSHF) on clear sky with that stored in the same conditions in Uccle (Brussels), the Belgian reference station (Royal meteorological institute, RMI) and urban area

The clinical pathways as a support for transversal measures of patient care organization: a bottom-up project management experience

Notre travail apporte une contribution à l’étude de l’évolution de l’organisation des soins de santé par une intégration des activités cliniques, de recherche et d’enseignement, dans une gestion de projet bottom-up qui vise l’intégration de processus multidisciplinaires et transversaux de soins au patient. D’un projet de recherche est né un projet de service, pour le développement d’un programme d’épargne sanguine en chirurgie cardiaque. Ce projet se concrétise par l’élaboration d’un itinéraire clinique en chirurgie cardiaque. La méthodologie des itinéraires cliniques intègre le nouveau plan stratégique institutionnel ; la notion de « Parcours de Soins » est développée et renforce l’implémentation des mesures relevant des axes stratégiques « Parcours du patient » et « Soins Intégrés », tout en trouvant écho dans les nouvelles normes législatives d’agrément et d’accréditation. L’ensemble des recherches et projets qui ont été menés dans ce contexte mettent en lumière la valeur de la discipline infirmière pour l’intégration de la recherche et de la clinique dans les processus de soins. Ces éléments sont enseignés aux étudiants du Master en Sciences de la Santé publique via des missions d’enseignement, notamment dans le cadre de la nouvelle finalité spécialisée « Pratiques avancées en science infirmière ».Our work contributes to the study of the health care organization’s evolution, by an integrating approach of clinical, research and teaching fields, in a bottom-up project management which aims integration of multidisciplinary and transversal care processes. From a research project was born a service project for the development of a blood management program in cardiac surgery. This project led to the development of a clinical pathway in cardiac surgery. The methodology of clinical pathways has been integrated in the new institutional strategic plan; the concept of “Care pathways” is developed to reinforce the implementation of "patient's pathway" and "Integrated Care" measures. This concept also finds an echo in the legislative and accreditation standards. Our researches and projects highlight the value of nurses for the integration of research and clinical care process. This approach is taught to Public Health Science Master’s students through educational missions in the Advanced Practice Nursing Science

Percutaneous aortic valve implantation: Nursing care - Results - Quality of life

La littérature internationale récente contient de nombreuses études décrivant les résultats de l’implantation percutanée d’une valve aortique (IPVA), mais à notre connaissance, aucune n’a décrit la surveillance infirmière requise après cette procédure. L’efficacité de l’IPVA est évaluée sur la base de paramètres cliniques et hémodynamiques tandis que l’autonomie du patient et sa qualité de vie ne sont que rarement étudiés. Pourtant, il ne faut pas sous-estimer l’importance pour la personne âgée, de la conservation d’une autonomie et d’une qualité de vie raisonnable, par rapport à une éventuelle prolongation de la durée de vie. Les objectifs de cette étude sont : 1) définir la surveillance infirmière à mettre en place aux Soins Intensifs après IPVA 2) déterminer les éléments à optimaliser afin d’améliorer les résultats de la procédure 3) évaluer l’impact de l’IPVA sur l’autonomie et la qualité de vie du patien