Comment mettre en application des recommandations de pratique clinique? L'exemple des dyslipidémies [How to apply clinical guidelines in medical practice? The example of dyslipidemia]

How to summarize and facilitate the implementation of national and international guidelines in clinical practice? To adress these issues, we present a summary of dyslipidemia management for general practitioners. To achieve these aims, we adopted strategies based on international and national guidelines and focused on clinical applications which implies to choose specific options, such as the use of cardiovascular risk score and specific therapies as first options.

Clinical review: Update on neurally adjusted ventilatory assist - report of a round-table conference.

ABSTRACT: Conventional mechanical ventilators rely on pneumatic pressure and flow sensors and controllers to detect breaths. New modes of mechanical ventilation have been developed to better match the assistance delivered by the ventilator to the patient's needs. Among these modes, neurally adjusted ventilatory assist (NAVA) delivers a pressure that is directly proportional to the integral of the electrical activity of the diaphragm recorded continuously through an esophageal probe. In clinical settings, NAVA has been chiefly compared with pressure-support ventilation, one of the most popular modes used during the weaning phase, which delivers a constant pressure from breath to breath. Comparisons with proportional-assist ventilation, which has numerous similarities, are lacking. Because of the constant level of assistance, pressure-support ventilation reduces the natural variability of the breathing pattern and can be associated with asynchrony and/or overinflation. The ability of NAVA to circumvent these limitations has been addressed in clinical studies and is discussed in this report. Although the underlying concept is fascinating, several important questions regarding the clinical applications of NAVA remain unanswered. Among these questions, determining the optimal NAVA settings according to the patient's ventilatory needs and/or acceptable level of work of breathing is a key issue. In this report, based on an investigator-initiated round table, we review the most recent literature on this topic and discuss the theoretical advantages and disadvantages of NAVA compared with other modes, as well as the risks and limitations of NAVA.

Decoding auditory EEG responses in healthy and clinical populations: A comparative study.

BACKGROUND: Analyses of brain responses to external stimuli are typically based on the means computed across conditions. However in many cognitive and clinical applications, taking into account their variability across trials has turned out to be statistically more sensitive than comparing their means. NEW METHOD: In this study we present a novel implementation of a single-trial topographic analysis (STTA) for discriminating auditory evoked potentials at predefined time-windows. This analysis has been previously introduced for extracting spatio-temporal features at the level of the whole neural response. Adapting the STTA on specific time windows is an essential step for comparing its performance to other time-window based algorithms. RESULTS: We analyzed responses to standard vs. deviant sounds and showed that the new implementation of the STTA gives above-chance decoding results in all subjects (in comparison to 7 out of 11 with the original method). In comatose patients, the improvement of the decoding performance was even more pronounced than in healthy controls and doubled the number of significant results. COMPARISON WITH EXISTING METHOD(S): We compared the results obtained with the new STTA to those based on a logistic regression in healthy controls and patients. We showed that the first of these two comparisons provided a better performance of the logistic regression; however only the new STTA provided significant results in comatose patients at group level. CONCLUSIONS: Our results provide quantitative evidence that a systematic investigation of the accuracy of established methods in normal and clinical population is an essential step for optimizing decoding performance.

Probiotic interventions in infancy: Benefit and Safety Assessment of Extended Applications

Immaturity of the gut barrier system in the newborn has been seen to underlie a number of chronic diseases originating in infancy and manifesting later in life. The gut microbiota and breast milk provide the most important maturing signals for the gut-related immune system and reinforcement of the gut mucosal barrier function. Recently, the composition of the gut microbiota has been proposed to be instrumental in control of host body weight and metabolism as well as the inflammatory state characterizing overweight and obesity. On this basis, inflammatory Western lifestyle diseases, including overweight development, may represent a potential target for probiotic interventions beyond the well documented clinical applications. The purpose of the present undertaking was to study the efficacy and safety of perinatal probiotic intervention. The material comprised two ongoing, prospective, double-blind NAMI (Nutrition, Allergy, Mucosal immunology and Intestinal microbiota) probiotic interventions. In the mother-infant nutrition and probiotic study altogether 256 women were randomized at their first trimester of pregnancy into a dietary intervention and a control group. The intervention group received intensive dietary counselling provided by a nutritionist, and were further randomized at baseline, double-blind, to receive probiotics (Lactobacillus rhamnosus GG and Bifidobacterium lactis) or placebo. The intervention period extended from the first trimester of pregnancy to the end of exclusive breastfeeding. In the allergy prevention study altogether 159 women were randomized, double-blind, to receive probiotics (Lactobacillus rhamnosus GG) or placebo 4 weeks before expected delivery, the intervention extending for 6 months postnatally. Additionally, patient data on all premature infants with very low birth weight (VLBW) treated in the Department of Paediatrics, Turku University Hospital, during the years 1997 - 2008 were utilized. The perinatal probiotic intervention reduced the risk of gestational diabetes mellitus (GDM) in the mothers and perinatal dietary counselling reduced that of fetal overgrowth in GDM-affected pregnancies. Early gut microbiota modulation with probiotics modified the growth pattern of the child by restraining excessive weight gain during the first years of life. The colostrum adiponectin concentration was demonstrated to be dependent on maternal diet and nutritional status during pregnancy. It was also higher in the colostrum received by normal-weight compared to overweight children at the age of 10 years. The early perinatal probiotic intervention and the postnatal probiotic intervention in VLBW infants were shown to be safe. To conclude, the findings in this study provided clinical evidence supporting the involvement of the initial microbial and nutritional environment in metabolic programming of the child. The manipulation of early gut microbial communities with probiotics might offer an applicable strategy to impact individual energy homeostasis and thus to prevent excessive body-weight gain. The results add weight to the hypothesis that interventions aiming to prevent obesity and its metabolic consequences later in life should be initiated as early as during the perinatal period.

Mass spectrometry in clinical proteomics - from the present to the future

MS is an important analytical tool in clinical proteomics, primarily in the disease-specific discovery identification and characterisation of proteomic biomarkers and patterns. MS-based proteomics is increasingly used in clinical validation and diagnostic method development. The latter departs from the typical application of MS-based proteomics by exchanging some of the high performance of analysis for the throughput, robustness and simplicity required for clinical diagnostics. Although conventional MS-based proteomics has become an important field in clinical applications, some of the most recent MS technologies have not yet been extensively applied in clinical proteomics. in this review, we will describe the current state of MS in clinical proteomics and look to the future of this field.

A NEW FIBRIN SEALANT FROM Crotalus durissus terrificus VENOM: APPLICATIONS IN MEDICINE

Fibrin sealant, a widely available tissue adhesive, has been used since 1940 in a variety of clinical applications. Commercially available fibrin sealant products are synthesized from bovine thrombin and human fibrinogen, which may transmit infectious diseases, and recipients may also develop antibodies against bovine thrombin. Bearing these disadvantages in mind, a new fibrin sealant was developed in 1989 by a group of researchers from the Center for the Study of Venoms and Venomous Animals, in São Paulo State, Brazil. The main purpose was to produce an adhesive fibrin without using human blood, to avoid transmitting infectious diseases. The components of this novel sealant were extracted from large animals and a serine proteinase extracted from Crotalus durissus terrificus snake venom. The applicability of this sealant was tested in animals and humans with beneficial results. The new fibrin sealant can be a useful tool clinically due to its flexibility and diversity of applications. This sealant is a biological and biodegradable product that ( 1) does not produce adverse reactions, ( 1) contains no human blood, ( 3) has a good adhesive capacity, ( 4) gives no transmission of infectious diseases, and ( 5) may be used as an adjuvant in conventional suture procedures. The effectiveness of this new fibrin sealant is reviewed and its development and employment are described.

Clinical feasibility of cognitive testing in dogs (Canis lupus familiaris)

Several cognitive tests have been developed to evaluate specific aspects of human and animal learning and memory. These tests have been used for early detection of cognitive deficits and to monitor the treatment of dogs with cognitive impairment. Thus, this article evaluated the feasibility of cognitive tests for use in canine neurology clinical routines and the suitability of the different tests to accomplish this aim. Fifteen healthy adult dogs were used for the cognitive tests of reward approach learning, object approach learning, object discrimination learning, reversal learning, delayed non-matched to position, and delayed non-matched to sample to assess different aspects of memory. No difference was observed between tests of delayed non-matched to position (3.13 +/- 2.23 days) and delayed non-matched to sample (3.20 +/- 2.40 days) (P = 0.944). However, dogs had greater difficulty in reversal learning (8.47 +/- 2.61 days) than in object discrimination learning (4.60 +/- 1.64 days) (P <= 0.001). Based on the tests performed, the delayed non-matched to position test may be performed in clinical routine if the owner and the veterinarian have time available, because this test is sensitive to evaluate dogs with cognitive impairments, but requires approximately 10 days of training. Thus, elderly dogs are excellent experimental models to study pathological aging based on their similarities with some human brain diseases, such as Alzheimer disease. (C) 2014 Elsevier Inc. All rights reserved.

Piezosurgery Applied to Implant Dentistry: Clinical and Biological Aspects

Piezosurgery is a new and modern technique of bone surgery in implantology. Selective cutting is possible for different ultrasonic frequencies acting only in hard tissues (mineralized), saving vital anatomical structures. With the piezoelectric osteotomy technique, receptor site preparation for implants, autogenous bone graft acquistition (particles and blocks), osteotomy for alveolar bone crest expansion, maxillary sinus lifting, and dental implant removal can be performed accurately and safely, providing excellent clinical and biological results, especially for osteocyte viability. The aim of this review was, through literature review, to present clinical applications of piezosurgery in implant dentistry and outline their advantages and disadvantages over conventional surgical systems. Moreover, this study addressed the biological aspects related to piezosurgery that differentiate it from those of bone tissue approaches. Overall, piezosurgery enables critical operations in simple and fully executable procedures; and effectively, areas that are difficult to access have less risk of soft tissue and neurovascular tissue damage via piezosurgery.

The Fresh Frozen Bone Allograft (FFBA) to reconstruc the atrophic maxilla: evaluation of the clinical and histological viability at six and nine months in the maxillary sinus

This work aimed to analyze clinically and histologically the allogen bone graft behavior at 6 and 9 months. A leukoderm, female, 55 years old patient sought dental care for oral rehabilitation with dental implants and implant supported fixed prosthesis in the maxilla. Bilateral sinus lifting procedure were performed in a same patient, the analysis were made after 6 and 9 months, respectively. At 6 months, there was lack of a better bone remodeling in the region, associated to the presence of fibrous connective tissue within the collected tissue, showing us that this is not the best stage of tissue maturation to place dental implants. The 9 months period showed an improvement, with a more organized bone tissue surrounding particles of homogenous bone, what possibly had increased implant stability at the time of surgery. There is no doubt about the increase of clinical applications of FFBA, but there are no studies available regarding the standardization of time to load implants inserted in allografts. So papers with long-term monitoring are necessary to eliminate questions that still remain to be answered.

Cone Beam Computed Tomographic Imaging: Perspective, Challenges, and the Impact of Near-Trend Future Applications

Cone beam computed tomography (CBCT) can be considered as a valuable imaging modality for improving diagnosis and treatment planning to achieve true guidance for several craniofacial surgical interventions. A new concept and perspective in medical informatics is the highlight discussion about the new imaging interactive workflow. The aim of this article was to present, in a short literature review, the usefulness of CBCT technology as an important alternative imaging modality, highlighting current practices and near-term future applications in cutting-edge thought-provoking perspectives for craniofacial surgical assessment. This article explains the state of the art of CBCT improvements, medical workstation, and perspectives of the dedicated unique hardware and software, which can be used from the CBCT source. In conclusion, CBCT technology is developing rapidly, and many advances are on the horizon. Further progress in medical workstations, engineering capabilities, and improvement in independent software-some open source-should be attempted with this new imaging method. The perspectives, challenges, and pitfalls in CBCT will be delineated and evaluated along with the technological developments.

Role of outgrowth endothelial cells for applications in tissue engineering

Co-culture systems, consisting of outgrowth endothelial cells (OEC) and primary osteoblasts (pOB), represent a prom¬ising instrument to mimick the natural conditions in bone repair processes and provide a new concept to develop constructs for bone replacement. Furthermore, co-culture of OEC and pOB could provide new insights into the molecular and cellular mechanisms that control essential processes during bone repair. The present study described several advantages of the co-culture of pOB and OEC for bone tissue engineering applications, including beneficial effects on the angiogenic activation of OEC, as well as on the assembly of basement membrane matrix molecules and factors involved in vessel maturation and stabilization. The ongoing angiogenic process in the co-culture system proceeded during the course of co-cultivation and correlated with the upregulation of essential angiogenic factors, such as VEGF, angiopoietins, basement membrane molecules and mural cell-specific markers. Furthermore the co-culture system appeared to maintain osteogenic differentiation capacity.rnrnAdditional treatment of co-cultures with growth factors or morphogens might accelerate and improve bone formation and furthermore could be useful for potential clinical applications. In this context, the present study highlights the central role of the morphogen, sonic hedgehog, which has been shown to affect angiogenic activation as well as osteogenic differentiation in the co-culture model of OEC and pOB. Treatment of co-cultures with sonic hedgehog resulted in an increased formation of microvessel-like structures as early as after 24 hours. This proangiogenic effect was induced by the upregulation of the proangiogenic factors, VEGF, angiopoietin1 and angiopoietin 2. In contrast to treatment with a commonly used proangiogenic agent, VEGF, Shh stimulation induced an increased expression of factors associated with vessel maturation and stabilization, mediated through the upregulation of growth factors that are strongly involved in pericyte differentiation and recruitment, including PDGF-BB and TGFbeta. In addition, Shh treatment of co-cultures also resulted in an upregulation of osteogenic differentiation markers like alkaline phosphatase, osteocalcin, osteonectin and osteopontin, as well as an increased matrix calcification. This was a result of upregulation of the osteogenic differentiation regulating factors, BMP2 and RUNX2 which could be assessed in response to Shh treatment. rn

Multiplex assays for biomarker research and clinical application: translational science coming of age

Over the last decade, translational science has come into the focus of academic medicine, and significant intellectual and financial efforts have been made to initiate a multitude of bench-to-bedside projects. The quest for suitable biomarkers that will significantly change clinical practice has become one of the biggest challenges in translational medicine. Quantitative measurement of proteins is a critical step in biomarker discovery. Assessing a large number of potential protein biomarkers in a statistically significant number of samples and controls still constitutes a major technical hurdle. Multiplexed analysis offers significant advantages regarding time, reagent cost, sample requirements and the amount of data that can be generated. The two contemporary approaches in multiplexed and quantitative biomarker validation, antibody-based immunoassays and MS-based multiple (or selected) reaction monitoring, are based on different assay principles and instrument requirements. Both approaches have their own advantages and disadvantages and therefore have complementary roles in the multi-staged biomarker verification and validation process. In this review, we discuss quantitative immunoassay and multiple reaction monitoring/selected reaction monitoring assay principles and development. We also discuss choosing an appropriate platform, judging the performance of assays, obtaining reliable, quantitative results for translational research and clinical applications in the biomarker field.

Genitourinary applications of diffusion-weighted MR imaging in the pelvis

Diffusion-weighted (DW) magnetic resonance (MR) imaging has a large number of potential clinical applications in the female and male pelvis and can easily be added to any routine MR protocol. In the female pelvis, DW imaging allows improvement of staging in endometrial and cervical cancer, especially in locally advanced disease and in patients in whom contrast medium administration should be avoided. It can also be helpful in characterizing complex adnexal masses and in depicting recurrent tumor after treatment of various gynecologic malignancies. DW imaging shows promising results in monitoring treatment response in patients undergoing radiation therapy of cervical cancer. An increase in apparent diffusion coefficient (ADC) values of responders precedes changes in size and may therefore allow early assessment of treatment success. In the male pelvis, the detection of prostate cancer in the peripheral zone is relatively easier than in the central gland based on the underlying ADC values, whereas overlapping values reported in the central gland still need further research. DW imaging might also be applied in the noninvasive evaluation of bladder cancer to differentiate between superficial and muscle-invasive tumors. Initial promising results have been reported in differentiating benign from malignant pelvic lymph nodes based on the ADC values; however, larger-scale studies will be needed to allow the detection of lymph node metastases in an individual patient. Prerequisites for successfully performing DW imaging of the female and male pelvis are standardization of the DW imaging technique, including the choice of b values, administration of an antiperistaltic drug, and comparison of DW findings with those of morphologic MR imaging.

Classification of platelet concentrates (Platelet-Rich Plasma-PRP, Platelet-Rich Fibrin-PRF) for topical and infiltrative use in orthopedic and sports medicine: current consensus, clinical implications and perspectives.

Platelet concentrates for topical and infiltrative use - commonly termed Platetet-Rich Plasma (PRP) or Platelet-Rich Fibrin (PRF) - are used or tested as surgical adjuvants or regenerative medicine preparations in most medical fields, particularly in sports medicine and orthopaedic surgery. Even if these products offer interesting therapeutic perspectives, their clinical relevance is largely debated, as the literature on the topic is often confused and contradictory. The long history of these products was always associated with confusions, mostly related to the lack of consensual terminology, characterization and classification of the many products that were tested in the last 40 years. The current consensus is based on a simple classification system dividing the many products in 4 main families, based on their fibrin architecture and cell content: Pure Platelet-Rich Plasma (P-PRP), such as the PRGF-Endoret technique; Leukocyte- and Platelet-Rich Plasma (LPRP), such as Biomet GPS system; Pure Platelet-Rich Fibrin (P-PRF), such as Fibrinet; Leukocyte- and Platelet-Rich Fibrin (L-PRF), such as Intra-Spin L-PRF. The 4 main families of products present different biological signatures and mechanisms, and obvious differences for clinical applications. This classification serves as a basis for further investigations of the effects of these products. Perspectives of evolutions of this classification and terminology are also discussed, particularly concerning the impact of the cell content, preservation and activation on these products in sports medicine and orthopaedics.

Clinical Use of Quantitative Computed Tomography–Based Finite Element Analysis of the Hip and Spine in the Management of Osteoporosis in Adults: the 2015 ISCD Official Positions—Part II

The International Society for Clinical Densitometry (ISCD) has developed new official positions for the clinical use of quantitative computed tomography (QCT)-based finite element analysis of the spine and hip. The ISCD task force for QCT reviewed the evidence for clinical applications and presented a report with recommendations at the 2015 ISCD Position Development Conference. Here we discuss the agreed upon ISCD official positions with supporting medical evidence, rationale, controversy, and suggestions for further study. Parts I and III address the clinical use of QCT of the hip, and the clinical feasibility of existing techniques for opportunistic screening of osteoporosis using CT scans obtained for other diagnosis such as colonography was addressed.