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BACKGROUND:: The purpose of this study was to test the diagnostic performance of clinical judgment for the prediction of a significant injury with whole-body computed tomography scanning after high-energy trauma. METHODS:: The authors conducted an observational prospective study in a single level-I trauma center. Adult patients were included if they had an isolated high-energy injury. Senior trauma leaders were asked to make a clinical judgment regarding the likelihood of a significant injury before performance of a whole-body computed tomography scan. Clinical judgments were recorded using a probability diagnosis scale. The primary endpoint was the diagnosis of a serious-to-critical lesion on the whole-body computed tomography scan. Diagnostic performance was assessed using receiver operating characteristic analysis. RESULTS:: Of the 354 included patients, 127 patients (36%) had at least one injury classified as abbreviated injury score greater than or equal to 3. The area under the receiver operating characteristic curve of the clinical judgment to predict a serious-to-critical lesion was 0.70 (95% CI, 0.64 to 0.75%). The sensitivity of the clinical judgment was 82% (95% CI, 74 to 88%), and the specificity was 49% (95% CI, 42 to 55%). No patient with a strict negative clinical examination had a severe lesion (n = 19 patients). The sensitivity of the clinical examination was 100% (95% CI, 97 to 100%) and its specificity was 8% (95% CI, 5 to 13%). CONCLUSIONS:: Clinical judgment alone is not sufficient to reduce whole-body computed tomography scan use. In patients with a strictly normal physical examination, whole-body computed tomography scanning might be avoided, but this result deserves additional study in larger and more diverse populations of trauma patients. Copyright © by 2017, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved.

Boccon-Gibod I.,Grenoble University Hospital Center | Bouillet L.,Grenoble University Hospital Center
Clinical and Experimental Immunology | Year: 2012

We evaluated the efficacy and safety of icatibant self-administration in 15 patients with hereditary angioedema (HAE) types I or III, for 55 acute attacks (mostly severe or very severe). Icatibant self-administration was generally effective: first symptom improvement occurred in 5min-2h (HAE type I; n=17) and 8min-1h (HAE type III; n=9) for abdominal attacks and 5-30min (HAE type I; n=4) and 10min-12h (HAE type III; n=6) for laryngeal attacks. Complete symptom resolution occurred in 15min-19h (HAE type I; n=8) and 15min-48h (HAE type III; n=9) for abdominal attacks and 5-48h (HAE type I; n=3) and 8-48h (HAE type III; n=5) for laryngeal attacks. No patient required emergency hospitalization. The only adverse events were mild, spontaneously resolving injection site reactions. Patients reported that carrying icatibant with them gave them greater confidence in managing their condition. © 2012 The Authors. Clinical and Experimental Immunology © 2012 British Society for Immunology.

Bouillet L.,Grenoble University Hospital Center
Expert Review of Clinical Immunology | Year: 2011

Hereditary angioedema (HAE) is a rare condition. Its prognosis depends on whether there is laryngeal involvement with a risk of asphyxia, which is present in 25% of such cases. Improved understanding of the pathophysiology of this disease has resulted in the development of targeted therapies including icatibant, which acts as an antagonist at bradykinin B2 receptors. This agent has been shown to be effective in the treatment of attacks of HAE in three Phase III randomized double-blind published studies. Efficacy data have been collected in all types of attack: cutaneous, abdominal and laryngeal. Safety data are also encouraging. Icatibant is administered subcutaneously, with the potential for patients to self-administer. In the future, this therapy may offer increased independence for HAE patients. © 2011 Expert Reviews Ltd.

An experience feedback committee (CREX, Comité de Retour d'EXpérience) is a method which contributes to the management of safety of care in a medical unit. Originally used for security systems of civil aviation, the method has been adapted to health care facilities and successfully implemented in radiotherapy units and in other specialties. We performed a brief review of the literature for studies reporting data on CREX established in hospitals. The review was performed using the main bibliographic databases and Google search results. The CREX is designed to analyse incidents reported by professionals. The method includes monthly meetings of a multi-professional committee that reviews the reported incidents, chooses a priority incident and designates a "pilot" responsible for investigating the incident. The investigation of the incident involves a systemic analysis method and a written synthesis presented at the next meeting of the committee. The committee agrees on actions for improvement that are suggested by the analysis and follows their implementation. Systems for the management of health care, including reporting systems, are organized into three levels: the medical unit, the hospital and the country as a triple loop learning process. The CREX is located in the base level, short loop of risk management and allows direct involvement of care professionals in patient safety. Safety of care has become a priority of health systems. In this context, the CREX can be a useful vehicle for the implementation of a safety culture in medical units. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Sahin M.,Grenoble University Hospital Center
Canadian journal of anaesthesia = Journal canadien d'anesthésie | Year: 2012

Endotracheal tube introducers are often used in difficult tracheal intubations, but they are rarely deemed responsible for airway injuries. There have been only a few reports of severe complications, such as pharyngeal perforation, mainstem bronchus bleeding, perforation of the tracheal mucosa, and tracheal abrasion associated with hemopneumothorax. Using a computed tomography (CT) scan, we illustrate two cases of non-severe airway injuries related to endotracheal tube introducers. We present two cases of distal bronchial lacerations caused by introducers. The first occurrence was caused by a Muallem ET Tube Stylet (METTS) in a patient who underwent surgery for a total thyroidectomy and presented hemoptysis at suction after tracheal intubation. The second occurrence was caused by an Eschmann® Tracheal Tube Introducer (gum elastic bougie) in a patient whose trachea was intubated before a radiofrequency ablation of a single lung metastasis. There was evidence of blood on the tip of the bougie after withdrawal. In both cases, a CT scan showed a post-traumatic bronchial laceration with an acquired bronchial ectasia surrounded by ground-glass opacity due to alveolar hemorrhage. The patients had no other clinical complications, and bronchial lesions resolved spontaneously at control CT scan. These two cases show that airway damage related to endotracheal tube introducers may not be exceptional. It is not unusual to have some blood on an airway management device, and the rate and severity of these lesions are unknown. However, damage to the airway can be avoided by adapting preventive techniques during tracheal intubation.

Murat J.B.,Grenoble University Hospital Center
Expert review of anti-infective therapy | Year: 2013

The Toxoplasma gondii parasite is a worldwide threat most particularly in fetal life and immunosuppression. In most clinical situations (except in some ocular cases), correct detection or identification of toxoplasmosis requires biological analysis. This article considers the laboratory tools that have been developed in this field since the discovery of the pathogen, with emphasis on the most recent tests and how they can or should be used in different clinical situations. The authors also discuss the requirements and pitfalls that one should be aware of when biologically investigating this intriguing parasitosis.

Strict glycaemic control is a major concern in many people with diabetes, hypoglycaemia being the most limiting factor in the daily management of patients with diabetes. Acute consequences of hypoglycaemic attacks are not precisely evaluated. Acute cardiovascular (CV) complications as myocardial ischaemia or stroke seem to be rare, but possibly ignored mainly in older frail patients. Recent large trials in type 2 diabetic patients have not shown the anticipated mortality benefits of strict glycaemic control, and reported a higher frequency of severe hypoglycaemia in the intensive treatment arms with an excess of CV deaths. The authors of these trials persist to deny a direct link between CV deaths and hypoglycaemia. In young type 1 diabetics "dead in bed" syndrome represents a rare but devastating consequence probably due to arrhythmia and prolonged QTc interval. Driving mishaps represent another complication but with a controversial frequency. Neurologic syndromes are frequent during severe hypoglycaemia but usually reversible. Major brain damages are scarce, but cognitive defects or dementia should be underestimated in older and frail type 2 diabetics. Thus, iatrogenic hypoglycaemia due to insulin or sulphonylureas may cause recurrent morbidity in type 1 and type 2 diabetic subjects, and should be prevented by a reevaluation of glycaemic targets in some patients, patient education and the use of new antidiabetic drugs without hypoglycaemic risk. Un contrôle glycémique strict est une préoccupation majeure chez beaucoup de diabétiques dont l'hypoglycémie est le principal facteur limitant au quotidien. Les conséquences aiguës et graves des hypoglycémies ne sont pas précisément évaluées. Les conséquences cardiovasculaires (CV), ischémie myocardique ou accidents vasculaires cérébraux semblent rares, mais peut-être ignorées surtout chez des patients âgés fragiles. De récents essais menés chez des diabétiques de type 2 n'ont pas montré les bénéfices anticipés du contrôle glycémique strict sur mortalité et rapporté une fréquence plus élevée d'hypoglycémies sévères dans le groupe de traitement intensif avec un excès de décès CV. Leurs auteurs ne retiennent aucun lien direct entre décès CV et hypoglycémies. Chez les jeunes diabétiques de type 1, le syndrome "du décès dans son sommeil" est une conséquence rare mais dramatique, sans doute due à des arythmies par allongement de l'intervalle QTc. Des accidents automobiles sont une autre complication, mais de fréquence controversée. Des syndromes neurologiques déficitaires sont fréquents au cours de l'hypoglycémie sévère, généralement réversibles. Les lésions cérébrales majeures sont rares mais les défauts cognitifs ou les démences restent sous-estimés chez les plus âgés. Ainsi, l'hypoglycémie iatrogène due à l'insuline ou aux sulfamides hypoglycémiants peut causer une morbidité significative chez des diabétiques de type 1 et 2. Elle devrait être évitée par une réévaluation des objectifs glycémiques chez certains patients, l'éducation thérapeutique et l'utilisation de nouveaux antidiabétiques sans risque d'hypoglycémie. © 2010 Elsevier Masson SAS.

Bonaz B.,Grenoble University Hospital Center
Minerva Gastroenterologica e Dietologica | Year: 2013

The gut has the capacity to function as an autonomous organ. However, in normal conditions, the gut and the central nervous system talk to each other through the autonomic nervous system (ANS), represented by the sympathetic (i.e. the splanchnic nerves) and the parasympathetic nervous system (i.e. the vagus nerve and the sacral parasympathetic pelvic nerves). The brain is able to integrate inputs coming from the digestive tract inside a central autonomic network organized around the hypothalamus, limbic system and cerebral cortex and in return to modify the ANS and the hypothalamic pituitary adrenal axis (HPA axis). An abnormal functioning of these brain-gut interactions has been described in irritable bowel syndrome (IBS) classically considered as a biopsychosocial model where stress plays a promoting role. Inflammatory bowel diseases (IBD) result from an inappropriate inflammatory response to intestinal microbes in a genetically susceptible host. In this article we review the current knowledge on the possible involvement of a dysfunction of brain-gut interactions in the pathogeny of IBD as represented by a dysfunction of the ANS, an abnormal HPA axis and cholinergic anti-inflammatory pathway, a deleterious effect of stress and depression as well as an abnormal coupling of the prefrontal cortex-amygdala complex and an abnormal relation between the microbiota and the brain as pro-inflammatory factors. Therapeutic approaches with the aim to restore an equilibrium of these brain-gut interactions are of interest.

Bonaz B.L.,Grenoble University Hospital Center | Bernstein C.N.,University of Manitoba
Gastroenterology | Year: 2013

Psycho-neuro-endocrine-immune modulation through the brain-gut axis likely has a key role in the pathogenesis of inflammatory bowel disease (IBD). The brain-gut axis involves interactions among the neural components, including (1) the autonomic nervous system, (2) the central nervous system, (3) the stress system (hypothalamic-pituitary-adrenal axis), (4) the (gastrointestinal) corticotropin-releasing factor system, and (5) the intestinal response (including the intestinal barrier, the luminal microbiota, and the intestinal immune response). Animal models suggest that the cholinergic anti-inflammatory pathway through an anti-tumor necrosis factor effect of the efferent vagus nerve could be a therapeutic target in IBD through a pharmacologic, nutritional, or neurostimulation approach. In addition, the psychophysiological vulnerability of patients with IBD, secondary to the potential presence of any mood disorders, distress, increased perceived stress, or maladaptive coping strategies, underscores the psychological needs of patients with IBD. Clinicians need to address these issues with patients because there is emerging evidence that stress or other negative psychological attributes may have an effect on the disease course. Future research may include exploration of markers of brain-gut interactions, including serum/salivary cortisol (as a marker of the hypothalamic-pituitary-adrenal axis), heart rate variability (as a marker of the sympathovagal balance), or brain imaging studies. The widespread use and potential impact of complementary and alternative medicine and the positive response to placebo (in clinical trials) is further evidence that exploring other psycho-interventions may be important therapeutic adjuncts to the conventional therapeutic approach in IBD. © 2013 AGA Institute.

To evaluate the reproducibility of US and to compare its efficacy with that of MRI and conventional radiography (CR) for the detection of bone erosion in RA patients. A systematic literature search was performed in the Medline, Embase and Cochrane databases up to August 2009. Trials evaluating the reproducibility of US for bone erosion detection or comparing the number of erosions detected by the three imaging methods at patient and/or joint level were included. This last parameter was assessed using the odds ratio (OR) and 95% CI with the Mantel-Haenszel method (OR < 1 favours US). We explored the heterogeneity between the studies by subgroup analysis. Twenty-one studies including 913 patients were included in this meta-analysis. Intraobserver and interobserver reproducibility of US for erosion detection was good. US and MRI efficacies were comparable at both joint (OR = 1.19, P = 0.45; seven studies, 869 joints) and patient (OR = 1.76, P = 0.22; nine studies, 338 patients) levels. US detected significantly more erosion than CR at both joint (OR = 0.30, P < 0.00001; 4047 joints studied) and patient (OR = 0.31, P < 0.00001; 592 studied patients) levels. The number of patients to screen in order to detect an additional patient with an erosion in comparison with CR was 4, 95% CI (2.4, 5.9). US is more effective for erosion detection than CR and has a comparable efficacy to MRI with good reproducibility.

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