L'instance d'appel dans le procès civil

L’instance d’appel est depuis toujours considérée par le droit français comme une garantie de bonne justice. Elle permet de faire redresser une erreur commise par le premier juge ayant tranché le litige. Ainsi, l’appel réalise une répétition du procès devant la cour d’appel, pour qu’il soit à nouveau statué en fait et en droit. On a donc pu parler de cette voie de recours comme une voie de réformation. Cependant, il s’est révélé impossible d’exiger une similitude exacte des éléments litigieux d’une instance à l’autre. Pour cette raison, des dérogations ont été admises, les textes et la jurisprudence ayant dû prendre acte des nécessités pratiques. Dès lors, l’appel a favorisé un renouvellement du procès, en intégrant devant la cour des éléments inédits. On s’est alors mis à parler de l’appel comme d’une voie d’achèvement. Cette évolution est peu à peu apparue excessive, et le besoin s’est fait sentir de la discipliner au nom d’une bonne administration de la justice. L’instance d’appel oscille constamment entre ces deux fonctions, la répétition et le renouvellement du procès civil. La physionomie de cette institution appelait inévitablement l’approfondissement que cette étude s’est proposée de réaliser et les solutions qu’elle s’est efforcée de dégager.The appeal body has always been considered by the French Law as a guarantee of equitable justice. It allows to redress errors committed by a trial judge who resolved a dispute in the first place. Thereby, the appeal enables a repetition of the trial before the appeal court, so that it may be examined again on points of fact and law. Thus, this plea approach has been described as a reformation approach. However, it proved impossible to demand an exact similarity of the dispute elements from one instance to another. As a consequence, and as the texts and jurisprudence had to take into consideration practical requirements, dispensations have been allowed. Since then, the appeal supported renewal of the trial, by incorporating previously unseen elements before the court. The appeal was then refered to as an achievement approach. This evolution gradually appeared as excessive, thereby justifying the need to control the appeal for a better administration of justice. The body of appeal oscillates constantly between these two functions, the repetition and the renewal of the civil trial. The features of this institution inevitably deserved further investigations and answers that this study proposed to carry out and identify

Treatment of sleep apnea in chronic heart failure patients with auto-servo ventilation improves sleep fragmentation: a randomized controlled trial

Background: Impaired sleep efficiency is independently associated with worse prognosis in patients with chronic heart failure (CHF). Therefore, a test was conducted on whether auto-servo ventilation (ASV, biphasic positive airway pressure [BiPAP]-ASV, Philips Respironics) reduces sleep fragmentation and improves sleep efficiency in CHF patients with central sleep apnea (CSA) or obstructive sleep apnea (OSA). Methods: In this multicenter, randomized, parallel group trial, a study was conducted on 63 CHF patients (age 64 +/- 10 years; left ventricular ejection fraction 29 +/- 7%) with CSA or OSA (apnea-hypopnea Index, AHI 47 +/- 18/h; 46% CSA) referred to sleep laboratories of the four participating centers. Participants were randomized to either ASV (n = 32) or optimal medical treatment alone (control, n = 31). Results: Polysomnography (PSG) and actigraphy at home (home) with centralized blinded scoring were obtained at baseline and 12 weeks. ASV significantly reduced sleep fragmentation (total arousal indexpsc: -16.4 +/- 20.6 vs.-0.6 13.2/h, p = 0.001; sleep fragmentation index(home):-7.6 +/- 15.6 versus 4.3 +/- 13.9/h, p = 0.003, respectively) and significantly increased sleep efficiency assessed by actigraphy (SEhome) compared to controls (2.3 +/- 10.1 vs.-2.1 +/- 6.9%, p = 0.002). Effects of ASV on sleep fragmentation and efficiency were similar in patients suffering from OSA and CSA. Conclusions: At home, ASV treatment modestly improves sleep fragmentation as well as sleep efficiency in CHF patients having either CSA or OSA. (C) 2015 Elsevier B.V. All rights reserved

An application of LARY_C : study of Cardio-vascular Rhythms Perturbations according to a Sleep Pathology (Periodic Leg Movements)

Projet SOSSOLARY_C is a software package, developped in the synchronous, data flow, parallel language SIGNAL, primary dedicated to the Autonomic Nervous System (ANS), through the analysis of physiological signals and their correlations: Heart Rate (HR), Arterial Blood Pressure (ABP), breathing, motility and electro-encephalographic activity (EEG). Our aim is to illustrate the new approach given by LARY_C for the processing of polygraphic recordings, through a clinical application, the nocturnal Periodic Leg Movements (PLM). Polygraphic recordings analysis, usually visually done, can't provide all the needed information, in particular the relations between rhythms are difficult to extract. The LARY_C library of medical signal processing provides a condense representation of the physiological rhythms; the SIGNAL synchronous environment provides the necessary tools to assess the relationships between these rhythms, in order to automatically produce a set of (cardiovascular) parameters related to an event (a PLM). We analysed the magnitude of the changes on HR and systolic ABP, the ANS behaviour through their activity in high and middle frequencies, the delays between the beginning of cardiovascular perturbations and the movement, and the relations with cortical activation reflected by an augmentation of $\alpha$ activity on the EEG. On one hundred PLM in a typical patient, cardiovascular changes related to movements are significant; the more often, they precede the movement and they are even more important in presence of high $\alpha$-activity. These preliminary results show PLM not only like a central nervous system dysfunction addressed to the motor system but rather like a dysfunction of reticular excitability responsible for motor, ANS and cortical activation. They ask the question of long term consequences of these cardiovascular swings and therefore of their specific treatement in addition to sleep and motor desorders one. Such an automatic approach seems appropriate for a better understanding of the physiopathology and to help the diagnostic in a large variety of clinical applications involving non-stationary, long duration polygraphic signals

Effects of Auto-Servo Ventilation on Patients with Sleep-Disordered Breathing, Stable Systolic Heart Failure and Concomitant Diastolic Dysfunction: Subanalysis of a Randomized Controlled Trial

Background: Systolic heart failure (HF) is frequently accompanied by diastolic dysfunction and sleep-disordered breathing (SDB). Objectives: The objective of this subset analysis was to determine effect sizes of auto-servo ventilation (ASV and biphasic positive airway pressure ASV) on echocardiographic measures of diastolic function in patients with systolic HF and SDB. Methods: Thirty-two patients with stable systolic HF, concomitant diastolic dysfunction [age 66 ± 9 years old, left ventricular (LV) ejection fraction: 30 ± 7% and New York Heart Association class II: 72%] and SDB (apnea-hypopnea index, AHI: 48 ± 19/h; 53% had predominantly obstructive sleep apnea) receiving either ASV (n = 19) or optimal medical treatment (control, n = 13) were analyzed in a randomized controlled clinical trial. Polysomnographic and echocardiographic measurements were obtained at baseline and after 12 weeks. Results: AHI significantly improved in the ASV group compared to the control group (-39 ± 18 vs. -0.2 ± 13.2/h, p < 0.001). At baseline, 24 (75%) patients had impaired LV relaxation, and 8 (25%) had a pseudo-normalized filling pattern. At the 12-week control visit, diastolic function assessed by the isovolumetric relaxation time (-10.3 ± 26.1 vs. 9.3 ± 49.1, p = 0.48) and deceleration time (-43.9 ± 88.8 vs. 12.4 ± 68.8, p = 0.40) tended to improve after ASV treatment, but did not reach statistical significance. Likewise, the proportion of patients whose diastolic dysfunction improved was nonsignificantly higher in the ASV than in the control group, respectively (37 vs. 15%, p = 0.25). Conclusions: ASV treatment efficiently abolishes SDB in patients with stable systolic HF and concomitant diastolic dysfunction, and was associated with a statistically nonsignificant improvement in measures of diastolic dysfunction. Thus, these data provide estimates of effect size and justify the evaluation of the effects of ASV on diastolic function in larger randomized controlled trials

Hypoxemia and Arrhythmia during Daily Activities and Six-minute Walk Test in Fibrotic Interstitial Lung Diseases

We performed 24-hr monitoring of pulse oximetric saturation (SpO2) with ECG and six-minute walk test (6MWT) in 19 patients with fibrotic interstitial lung diseases (ILD) to investigate; 1) The frequency and severity of hypoxemia and dysrhythmia during daily activities and 6MWT, 2) safety of 6MWT, and 3) the parameters of 6MWT which can replace 24-hr continuous monitoring of SpO2 to predict hypoxemia during daily activities. All patients experienced waking hour hypoxemia, and eight of nineteen patients spent > 10% of waking hours in hypoxemic state. Most patients experienced frequent arrhythmia, mostly atrial premature contractions (APCs) and ventricular premature contractions (VPCs). There were significant correlation between the variables of 6MWT and hypoxemia during daily activities. All of the patients who desaturated below 80% before 300 meters spent more than 10% of waking hour in hypoxemia (P = 0.018). In contrast to waking hour hypoxemia, SpO2 did not drop significantly during sleep except in the patients whose daytime resting SpO2 was already low. In conclusion, patients with fibrotic ILD showed significant period of hypoxemia during daily activities and frequent VPCs and APCs. Six-minute walk test is a useful surrogate marker of waking hour hypoxemia and seems to be safe without continuous monitoring of SpO2

Predictors of 1-year compliance with adaptive servoventilation in patients with heart failure and sleep disordered breathing: preliminary data from the ADVENT-HF trial

Despite its effectiveness in suppressing sleep disordered breathing (SDB), positive airway pressure therapy (PAP) is not always well tolerated by patients and long-term adherence can be problematic. Recently, two multicentre, randomised clinical trials (RCTs) tested the effects of PAP for patients with cardiovascular disease and co-existing SDB on morbidity and mortality with negative outcomes [1, 2]. Relatively poor adherence to PAP therapy (mean 3.7 and 3.3 h·day-1, respectively) in these two trials might have contributed to their poor results. Indeed, higher PAP use per day is associated with better clinical outcomes than lower use [3]