[Air transport, aeronautic medicine, health]. / Influences du transport aérien sur la santé.

There were 3.2 billion airline passengers in 2006, compared to only 30 million in 1950. Intercontinental health disparities create a risk of pandemics such as SARS and so-called bird flu. Precautions are now being implemented both in airports and in aircraft, in addition to measures intended to prevent the spread of malaria and arboviral diseases, such as vector eradication, elimination of stagnant water, malaria prophylaxis, vaccination, and use of repellents. These measures are dealt with in international health regulations, which have existed since 1851 and were last updated on 15 June 2007. Flying on an airliner also carries a risk of hypobaria (cabin pressure at 2000 m), which can aggravate respiratory problems. Other problems include relative hypoxia, gas expansion, air dryness, ozone, cosmic rays, airsickness, jet lag, the effects of alcohol and tobacco, and, more recently, deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively known as "coach class syndrome". A new type of medicine has appeared, in the form of on-board medical assistance. The European Civil Aviation Committee has recommended first-aid training for cabin crews and onboard medical equipment such as first-aid kits and defibrillators. Airline statistics show that one in-flight medical incident occurs per 20 000 passengers, as well as one death per 5 million passengers and one medical reroute per 20 000 flights (40% of reroutes turn out to be unjustified). More than 80% of long-haul flights have a physician travelling on board. However, depending on his or her specialty, problems of competence and legal responsibility may arise. Ground-based medical centers can provide help via satellite telephone, but this implies the need for airline staff training. International cooperation is the only way to minimize the health risks associated with the growth in global air travel.

Differential diagnostic value of procalcitonin in surgical and medical patients with septic shock.

OBJECTIVE: To assess whether different diagnostic and prognostic cutoff values of procalcitonin should be considered in surgical and in medical patients with septic shock. DESIGN: Prospective observational study. SETTING: Intensive care unit of the Avicenne teaching hospital, France. PATIENTS: All patients with septic shock or noninfectious systemic inflammatory response syndrome within 48 hrs after admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were allocated to one of the following groups: group 1 (surgical patients with septic shock), group 2 (surgical patients with noninfectious systemic inflammatory response syndrome), group 3 (medical patients with septic shock), and group 4 (medical patients with noninfectious systemic inflammatory response syndrome). Procalcitonin at study entry was compared between group 1 and group 2 and between group 3 and group 4 to determine the diagnostic cutoff value in surgical and in medical patients, respectively. Procalcitonin was compared between survivors and nonsurvivors from group 1 and group 3 to determine its prognostic cutoff value. One hundred forty-three patients were included: 31 in group 1, 36 in group 2, 36 in group 3, and 40 in group 4. Median procalcitonin levels (ng/mL [interquartile range]) were higher in group 1 than in group 3 (34.00 [7.10-76.00] vs. 8.40 [3.63-24.70], p = .01). In surgical patients, the best diagnostic cutoff value was 9.70 ng/mL, with 91.7% sensitivity and 74.2% specificity. In medical patients, the best diagnostic cutoff value was 1.00 ng/mL, with 80% sensitivity and 94% specificity. Procalcitonin was a reliable early prognostic marker in medical but not in surgical patients with septic shock. A cutoff value of 6.00 ng/mL had 76% sensitivity and 72.7% specificity for separating survivors from nonsurvivors. CONCLUSIONS: The diagnostic cutoff value of procalcitonin was higher in surgical than in medical patients. Early procalcitonin was of prognostic interest in medical patients.

[Determination of early markers of a sanitary event. The example of the heat wave of August 2003 at the Samu 93-centre 15 in France]. / Détermination des indicateurs précoces d'une crise sanitaire. L'exemple de la canicule d'août 2003 au Samu 93-centre 15.

OBJECTIVE: The aim of this study was to determine, a posteriori, the parameters detecting an event in a French medical emergency dispatching centre (SAMU). METHODS: Six parameters were retained: total number of medical requests received by the Samu 93-centre 15: the number of decisions to send a mobile intensive care unit (MICU), number of decisions to send a non-medical unit, number of decisions to send a general practitioner and number of deaths observed by the physicians of the MICU. For each parameter, a daily referential was established over the five previous years (1998 to 2002) and compared with the results of August 2003 RESULTS: The number of decisions to send a non-medical unit and the number of decisions to send a general practitioner were unchanged. The number of deaths on the 8th of August observed by the MICU physician should have led to an alert being given: 5.0 deaths for a referential of 1.7 (+ 194%). The number of decisions to send an MICU on the 7th of August should have led to an alert being given: 41 interventions for a referential of 25 (+64%). The number of medical interventions on the 6th of August should have led to an alert being given: 351 interventions for a referential of 299 (+17%). CONCLUSION: The total number of medical interventions treated by the SAMU 93-centre 15 is a the most sensitive and earliest marker of a sanitary event, such as that observed in August 2003 with the heat wave.

Recombinant activated factor VII decreases bleeding without increasing arterial thrombosis in rabbits.

PURPOSE: To compare the effects of recombinant activated factor VII (rFVIIa) and platelet-rich plasma (PRP) in an experimental model of bleeding and arterial thrombosis. METHODS: The Folts model was used in 60 rabbits. After anesthesia, the carotid artery was exposed and a 75% stenosis was induced. A compression injury of the artery triggered a series of cyclic flow reductions (CFRs). After counting baseline CFRs, animals were assigned randomly to one of four groups (n = 15 in each): control, PRP, rFVIIa and placebo. Control animals received 10 mL.kg(-1) of saline while 10 mL.kg(-1) of a hydroxyethyl starch solution (200,000/6%/0.5) were infused in the three other groups. CFRs were measured again, followed by treatment with PRP, rFVIIa or placebo and by a final measurement of CFRs. At the end of each observation period, an ear immersion bleeding time (BT) was measured and a blood sample was drawn for the evaluation of hematological variables. Microvascular bleeding was evaluated at the end of the experiment in grams of blood shed from liver and spleen sections. Results are presented as median (range). RESULTS: rFVIIa shortened the BT and decreased microvascular bleeding as compared with placebo [60 (35-100) sec vs 110 (50-140) sec, P = 0.0019 and 9 (4-24) g vs 17 (5-28) g, P = 0.002, respectively]. rFVIIa did not increase CFRs [3(0-9) vs |(0-5), P = 0.11]. CONCLUSION: rFVIIa led to a decrease in BT and microvascular bleeding but did not significantly affect arterial thrombosis in rabbits.

Diagnostic and prognostic value of procalcitonin in patients with septic shock.

OBJECTIVE: To determine whether procalcitonin is a reliable diagnostic and prognostic marker in septic shock compared with nonseptic shock. DESIGN: Prospective controlled trial. SETTING: Intensive care unit of the Avicenne Teaching Hospital, Bobigny, France. PATIENTS: All patients admitted to our intensive care unit over a 12-month period with clinical evidence of shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Echocardiography or pulmonary artery flotation catheter measurements were used to assess hemodynamics, and multiple specimens were obtained for microbiological studies. Standard criteria were used to diagnose septic shock. Serum concentrations of procalcitonin, C-reactive protein, and lactate were determined on the day of shock onset (day 1) and on days 3, 7, and 10. Seventy-five patients were included, 62 in the septic shock group and 13 in the cardiogenic shock group. Serum procalcitonin on day 1 was significantly higher in patients with than without septic shock (median, 14 [0.3-767] ng/mL vs. 1 [0.5-36] ng/mL, p < .01). A cutoff value of 1 ng/mL had 95% sensitivity and 54% specificity for separating patients with and without sepsis. C-reactive protein failed to discriminate between these two groups. Among patients with sepsis, procalcitonin concentrations were significantly higher in those who died than in the survivors, at all four measurement time points (median, 16 [0.15-767] ng/mL vs. 6 [0.2-123] ng/mL, p = .045 on day 1; 6.5 [0.3-135] ng/mL vs. 1.05 [0.11-53] ng/mL, p = .02 on day 10). A cutoff value of 6 ng/mL on day 1 separated patients who died from those who survived with 87.5% sensitivity and 45% specificity. C-reactive protein was not helpful for predicting mortality. Serum lactate was a nonspecific prognostic marker. CONCLUSIONS: These data indicate that procalcitonin may be a valuable early diagnostic and prognostic marker in patients with septic shock.

Assessing residual neuromuscular blockade using acceleromyography can be deceptive in postoperative awake patients.

UNLABELLED: Postoperative awake patients may have significant residual neuromuscular block. In awake patients, the results of accelerometry are affected by extra movements to which the thumb may be subject. In this study, we evaluated the repeatability of train-of-four (TOF) ratio using acceleromyography in 253 patients recovering from anesthesia. Immediately after arrival in the postanesthesia care unit, the ulnar nerve was stimulated with TOF stimulation. The evoked response at the thumb was measured by the TOF-Watch apparatus. The current intensity was 30 mA. Two TOF stimulations were applied and recorded at 30-s intervals. A Bland-Altman test was used. The Kappa (kappa) test for clinical agreement between the two measurements was also calculated according to the presence or absence of a residual neuromuscular blockade, defined as a TOF ratio <0.9. According to the presence of a residual neuromuscular blockade, the paired TOF ratios were discordant in 61 patients (24%; 95% confidence interval, 21%-27%). The kappa test indicated a moderate agreement (k = 0.47). We demonstrated that accelerometry as used in this study is not always accurate. Two isolated acceleromyograph TOF ratios are not an accurate representation of the neuromuscular status of the patient recovering from anesthesia. IMPLICATIONS: Clinicians should be aware that acceleromyography as used in this study does not always provide precise train-of-four ratio measurements. Two isolated acceleromyograph train-of-four ratios are not an accurate representation of the neuromuscular status of the patient recovering from anesthesia.

Aminoglycoside and glycopeptide renal toxicity in intensive care patients studied by proton magnetic resonance spectroscopy of urine.

OBJECTIVE: Aminoglycoside and glycopeptide antibiotics are responsible for renal toxicity. In most cases, the nephrotoxicity is limited to a reversible tubular injury, but an acute and sustained renal failure may occur. The aim of our study was to explore the renal function of patients given these antimicrobial agents with proton magnetic resonance spectroscopy of urine. This technique is able to detect, in urine samples, a wide range of metabolites reflecting renal tubular function. The variables assessed by magnetic resonance spectroscopy were compared with the routine markers of renal function: creatinine, urea, and 24-hr urine volume. DESIGN: Prospective clinical study. SETTING: Intensive care unit. PATIENTS: All patients in an intensive care unit receiving an aminoglycoside and/or a glycopeptide were included in the study if they presented with signs of renal dysfunction. All experiments were performed on urine samples collected for the routine follow-up of these patients. INTERVENTION: Proton spectra were acquired with water suppression, and the peak intensity of each metabolite was reported in relationship to the intensity of the creatinine peak. MEASUREMENTS AND MAIN RESULTS: The ratio values obtained by magnetic resonance spectroscopy were compared with the values of creatininemia and blood urea obtained routinely by biochemistry and with the value of the 24-hr urine volume by logistic regression and general linear models. This statistical analysis showed that the ratio of dimethylamine to creatinine was highly correlated with creatininemia. CONCLUSIONS: Dimethylamine is an osmolyte released from the medullar region of the kidney. Thus, our study demonstrated that nephrotoxicity from aminoglycosides and glycopeptides is not limited to proximal tubular toxicity but also may involve the medullar region (Henle loop and collecting duct) of the nephron.