Réanimation cardio-pulmonaire et travail en équipe : réflexion autour du concept aéronautique de "Crew Resource Management"

La prise en charge intra-hospitalière des arrêts cardio-respiratoires s'appuie sur une application précoce des gestes de base de la réanimation cardio- pulmonaire (massage cardiaque, ventilation pulmonaire, défibrillation) par les soignants. À l'heure actuelle, les formations à la réanimation cardio-pulmonaire impliquent uniquement l'apprentissage de gestes techniques et de connaissances théoriques, mais omettent totalement les aspects relationnels, ainsi que les problèmes de communication et de travail en équipe. Au travers d'une revue critique de la littérature médicale et aéronautique, nous proposons une nouvelle piste de formation dans le domaine de la réanimation cardio-pulmonaire. En s'appuyant sur les travaux réalisés dans l'aviation, dans les domaines de l'erreur humaine et du travail en équipe, nous offrons finalement une adaptation du "Crew Resource Management" ainsi qu'une série de recommandations, visant à intégrer les éléments relationnels et le facteur humain dans les cours de réanimations cardio-pulmonaires.

Reshaping the remodelled left ventricle: a new concept.

OBJECTIVE: Based on the law of Laplace, transventricular tension members were designed to diminish wall stress by changing the left ventricle (LV) globular shape to a bilobular one, thus reducing the ventricular wall radius of curvature. This concept was tested in a model of congestive heart failure. METHODS: Seven calves were used for the study (74.3+/-4.2 kg). Treatment efficacy was assessed with sonomicrometric wall motion analysis coupled with intraventricular pressure measurement. Preload increase was applied stepwise with tension members in released and tightened position. RESULTS: Tightening of the tension members improved systolic function for CVP>10 mmHg (dP/dt: 828+/-122 vs. 895+/-112 mmHg/s, P=0.019, for baseline and 20% stress level reduction respectively; wall thickening: 11.6+/-1.5 vs. 13.3+/-1.7%, P<0.001) and diastolic function (LV end-diastolic pressure: 15.9+/-4.8 vs. 13.6+/-2.7 mmHg, P<0.001, for CVP>10 mmHg; peak rate of wall thinning: -12.2+/-2.2 vs. -14+/-2.3 cm(2)/s, P<0.001 and logistic time constant of isovolumic relaxation: 48.4 +/-10.9 vs. 39.8+/-9.6ms, P<0.001, for CVP>5 mmHg). CONCLUSIONS: This less aggressive LV reduction method significantly improves contractility and relaxation parameters in this model of congestive heart failure.

C/EBPbeta couples dopamine signalling to substance P precursor gene expression in striatal neurones.

Dopamine-induced changes in striatal gene expression are thought to play an important role in drug addiction and compulsive behaviour. In this study we report that dopamine induces the expression of the transcription factor CCAAT/Enhancer Binding Protein beta (C/EBP)-beta in primary cultures of striatal neurones. We identified the preprotachykinin-A (PPT-A) gene coding for substance P and neurokinin-A as a potential target gene of C/EBPbeta. We demonstrated that C/EBPbeta physically interacts with an element of the PPT-A promoter, thereby facilitating substance P precursor gene transcription. The regulation of PPT-A gene by C/EBPbeta could subserve many important physiological processes involving substance P, such as nociception, neurogenic inflammation and addiction. Given that substance P is known to increase dopamine signalling in the striatum and, in turn, dopamine increases substance P expression in medium spiny neurones, our results implicate C/EBPbeta in a positive feedback loop, changes of which might contribute to the development of drug addiction.

Investigations on hydrogen isotope ratios of endogenous urinary steroids: reference-population-based thresholds and proof-of-concept.

Carbon isotope ratio (CIR) analysis has been routinely and successfully used in sports drug testing for many years to uncover the misuse of endogenous steroids. One limitation of the method is the availability of steroid preparations exhibiting CIRs equal to endogenous steroids. To overcome this problem, hydrogen isotope ratios (HIR) of endogenous urinary steroids were investigated as a potential complement; results obtained from a reference population of 67 individuals are presented herein. An established sample preparation method was modified and improved to enable separate measurements of each analyte of interest where possible. From the fraction of glucuronidated steroids; pregnanediol, 16-androstenol, 11-ketoetiocholanolone, androsterone (A), etiocholanolone (E), dehydroepiandrosterone (D), 5α- and 5β-androstanediol, testosterone and epitestosterone were included. In addition, sulfate conjugates of A, E, D, epiandrosterone and 17α- and 17β-androstenediol were considered and analyzed after acidic solvolysis. The obtained results enabled the calculation of the first reference-population-based thresholds for HIR of urinary steroids that can readily be applied to routine doping control samples. Proof-of-concept was accomplished by investigating urine specimens collected after a single oral application of testosterone-undecanoate. The HIR of most testosterone metabolites were found to be significantly influenced by the exogenous steroid beyond the established threshold values. Additionally, one regular doping control sample with an extraordinary testosterone/epitestosterone ratio of 100 without suspicious CIR was subjected to the complementary methodology of HIR analysis. The HIR data eventually provided evidence for the exogenous origin of urinary testosterone metabolites. Despite further investigations on HIR being advisable to corroborate the presented reference-population-based thresholds, the developed method proved to be a new tool supporting modern sports drug testing procedures.

Iowa Substance Abuse Brief; Alcohol: Binge Drinking, May 2009, Issue 2

Binge drinking by Iowans is a serious problem. Binge drinking is commonly defined as five or more drinks of alcohol on the same occasion for men and four or more for women. The 2006 National Survey on Drug Use and Health (NSDUH) estimated that 11% (approximately 28,000) of Iowans 12-17 years of age and 51% (approximately 177,000) of Iowans ages 18-25 had engaged in binge drinking during the past month. Favorable community and peer norms about alcohol use and easy access both contribute to this problem. Consequences of binge drinking can be immediate, like alcohol poisoning or injury, or much more delayed such as an increased risk for stroke or alcoholism. In either case the results can be severe.

Iowa Substance Abuse Brief; Alcohol: Underage Drinking, September 2009, Issue 1

IN BRIEF • More than one in three 11th graders drank alcohol in the past month. • For every four 11th graders in Iowa, one engaged in binge drinking in the past month. • Binge drinking is defined as four or more drinks for females and five or more for males on the same occasion (i.e., at the same time or within a couple of hours of each other) on at least one day in the past 30 days. • A drink refers to one half ounce of alcohol (one 12-oz beer, one 5-oz glass of wine, or one 1-oz shot of 100 proof distilled spirits).

The concept of the inflammasome and its rheumatologic implications.

The inflammasome is a proteolytic complex that regulates IL1β and IL-18 secretion in macrophages and dendritic cells. Its plays a vital role in the control of the inflammatory and cellular responses to infectious and danger signals and is an essential part of the innate immune system. Four different inflammasomes have been identified so far, and the NLRP3-inflammasome has been the best-studied in relation to human disease. Activation of the NLRP3-inflammasome by microcrystals, such as monosodium urate (MSU) and basic calcium phosphate (BCP) crystals, leads to IL1β release, which in turn triggers local inflammation. Dysfunction of the NLRP3-inflammasome due to mutations of the NLRP3 gene is the cause of the auto-inflammatory syndrome CAPS. The symptoms and signs of inflammation in both conditions respond to IL1 blockade. IL1 inhibitors have also been used successfully in other idiopathic inflammatory diseases, suggesting that dysregulated inflammasome activity contributes to the pathogenesis of multiple diseases, but the precise underlying mechanisms remain to be identified.

A modular magnetic anastomotic device for minimally invasive digestive anastomosis: proof of concept and preliminary data in the pig model.

BACKGROUND: The aim of our study was to assess the feasibility of minimally invasive digestive anastomosis using a modular flexible magnetic anastomotic device made up of a set of two flexible chains of magnetic elements. The assembly possesses a non-deployed linear configuration which allows it to be introduced through a dedicated small-sized applicator into the bowel where it takes the deployed form. A centering suture allows the mating between the two parts to be controlled in order to include the viscerotomy between the two magnetic rings and the connected viscera. METHODS AND PROCEDURES: Eight pigs were involved in a 2-week survival experimental study. In five colorectal anastomoses, the proximal device was inserted by a percutaneous endoscopic technique, and the colon was divided below the magnet. The distal magnet was delivered transanally to connect with the proximal magnet. In three jejunojejunostomies, the first magnetic chain was injected in its linear configuration through a small enterotomy. Once delivered, the device self-assembled into a ring shape. A second magnet was injected more distally through the same port. The centering sutures were tied together extracorporeally and, using a knot pusher, magnets were connected. Ex vivo strain testing to determine the compression force delivered by the magnetic device, burst pressure of the anastomosis, and histology were performed. RESULTS: Mean operative time including endoscopy was 69.2 ± 21.9 min, and average time to full patency was 5 days for colorectal anastomosis. Operative times for jejunojejunostomies were 125, 80, and 35 min, respectively. The postoperative period was uneventful. Burst pressure of all anastomoses was ≥ 110 mmHg. Mean strain force to detach the devices was 6.1 ± 0.98 and 12.88 ± 1.34 N in colorectal and jejunojejunal connections, respectively. Pathology showed a mild-to-moderate inflammation score. CONCLUSIONS: The modular magnetic system showed enormous potential to create minimally invasive digestive anastomoses, and may represent an alternative to stapled anastomoses, being easy to deliver, effective, and low cost.

Secular trends in legal and illegal substance use among 16 to 20 year old adolescents in Switzerland.

BACKGROUND: Data targeting trends in legal and illegal substance use by adolescents are scarce. Using the data from two similar large national surveys run in 1993 and 2002, this paper assesses secular trends in rates of substance use among 16-20-year-old Swiss adolescents. METHODS: Self-reported regular use of tobacco, alcohol misuse, regular cannabis use (01 occasion over last 30 days) and lifetime use of psychoactive medication, LSD, ecstasy, cocaine and heroine were assessed through identical questions using an anonymous self-administered questionnaire. 9268 (1993) and 7428 (2002) high school students and apprentices were included in the analyses. RESULTS: There is a higher proportion of regular smokers among apprentices than among students (p <0.001). Between 1993 and 2002 the increase in regular tobacco consumption was significant among both female and male apprentices (p <0.001) but not among students. Between 1993 and 2002 alcohol misuse significantly increased in all four groups (p <0.001). It is more prevalent among males than among females (p <0.001) and higher among apprentices than among students (p <0.001). Regular use of cannabis has increased in the four groups (p <0.0001). It is higher among males than among females (p <0.001), while it is largely the same among students and apprentices. While the increase in ecstasy use is highly significant in all four groups (p <0.001), the increase in LSD and cocaine use is significant among apprentices only (p <0.001). Use of LSD, ecstasy and cocaine is more prevalent among males than among females (<0.001) and higher among apprentices than among students (p <0.001). CONCLUSION: The secular increase in psychoactive substance use among older Swiss adolescents calls for the implementation of effective strategies both from individual and public health viewpoints.