Biomechanical analysis of practitioner's gesture for peripheral venous catheter insertion.

Peripheral venous catheter insertion (PVCI) is one of the most common procedures performed by healthcare professionals but remains technically difficult. To develop new medical simulators with better representativeness of the human forearm, an experimental study was performed to collect data related to the puncturing of human skin and a vein in the antebrachial area. A total of 31 volunteers participated in this study. Force sensors and digital image correlation were used to measure the force during the palpation and puncturing of the vein and to retrieve the kinematics of the practitioner's gesture. The in vivo skin rupture load, vein rupture load, and friction loads for skin only and for both the skin and vein were (mean ± standard deviation) 0.85 ± 0.34 N, 1.25 ± 0.37 N, -0.49 ± 0.19 N, and -0.51 ± 0.16 N, respectively. The results of this study can be used to develop realistic skin and vein substitutes and mechanically assess them by reproducing the practitioner's gesture in a controlled fashion.

[Delays of treatment of acute myocardial infarction with ST elevation admitted to the CCU (coronary care unit) in Alsace]. / Délais de prise en charge de l'infarctus aigu du myocarde avec sus-décalage persistant du segment ST admis dans les USIC d'Alsace.

OBJECTIVE: to determine the time delay from symptom onset to diagnosis and treatment of patients with persistant ST segment elevation myocardial infarction (STEMI). DESIGN: prospective observational study. METHOD: patients with symptoms onset < 24 h admitted in all 10 cardiac intensive care units in one French administrative region (Alsace). Data were recorded by doctors on duty soon after hospital admission. Patients with STEMI during hospital stay or as a complication of cardiac interventional procedure were excluded. The Kruskal-Wallis test was used to assess statistical differences between the groups (p value < 0.05). RESULT: from April to October 2004, 326 patients were admitted for STEMI. Median time between the symptoms onset and the patient's call for medical help was 60 minutes. General practitioners were the first medical contact in 41%. The time from symptoms onset to first medical intervention and from first medical intervention to coronary care unit admission were markedly shorter in patients who had directly called the Emergency Medical Services (group 15-110 patients i.e. 33% of the study population): 44 min vs 75 min otherwise (p=0,003). Median transport time was 60 min. Sixty two percent of the pts were transported by the Emergency Medical Services. The median time from symptoms onset to initiation of reperfusion therapy was 240 min. It was significantly lower in group 15 (170 min vs 286 min - p < 0,001) and for thrombolytic therapy (190 min versus 245 min for primary angioplasty, p=0,007). When thrombolysis (THL) was used, 89% of the pts could be treated during 6 hours of symptoms onset and 44% in 3 hours. For angioplasty only 4% of the pts were treated in the first 90 minutes, 9% in the 2 hours and 30% in the 3 hours of symptoms onset. If the time delay is evaluated from the 1 st medical intervention, call to reperfusion intervention was significatly shorter for THL: 91 versus 157 min, p< 0,003. Angioplasty represented 75% of reperfusion strategy in our area and THL alone only 2,7% and combine therapy 5,4%. CONCLUSION: our study documents the beneficial effect of a direct call to Emergency Medical Services. Our results also underscore the need for an effort to reduce the time to offer the best appropriate reperfusion techniques in STEMI pts: speed up the admission in the cath-lab, think about pre-hospital thrombolysis followed by coronary angioplasty if necessary.

Disease expression of Lyme borreliosis in northeastern France.

Since very little is known about the clinical expression of Lyme borreliosis in Western Europe, a 3-year prospective study was conducted that included all patients seen for suspected Lyme borreliosis at the Strasbourg University Hospital in northeastern France. The diagnosis of Lyme borreliosis was made on the basis of the presence of erythema migrans or on the basis of another suggestive clinical manifestation and laboratory confirmation. A total of 132 patients, 70 women and 62 men, mean age 54 years, had Lyme borreliosis according to these criteria. Within this study group, 77% of the patients were regularly exposed to tick bites and 64% could remember one. Erythema migrans, the most frequent clinical manifestation, occurred in 60% of the patients and was the only sign of Lyme borreliosis in 40%. Lymphocytoma and acrodermatitis chronica atrophicans were rare (1 and 3 patients, respectively). Nervous system involvement (mainly radiculoneuropathy), the second most common clinical manifestation, was found in 40% of the patients and was the only sign of Lyme borreliosis in 22%. Musculoskeletal involvement was present in 26% of the patients and was an isolated finding in 14%. During the study period, no patient was diagnosed with Lyme carditis. There was serological evidence of Lyme borreliosis in 75% of the cases and direct evidence of borrelial infection in 10 (7.5%). The results show that the clinical expression of Lyme borreliosis in northeastern France is similar to that in other European countries but different from that in North America.

[Use of heparin in unstable angina and non-Q-wave infarction]. / Utilisation des héparines dans l'angor instable et l'infarctus sans onde Q.

The limitations of conventional treatment by non-fractionated heparin (NFH) in unstable angina and non-Q wave infarction with a serious adverse event rate (infarction and/or death) of 7 to 9% at 30 days have led to research in the use of low molecular weight heparin (LMWH). In 1995, Gurfinkel et al reported the superiority of the association aspirin-LMWH (Nadroparine) over a more classical treatment with aspirin alone or the association of aspirin-NFH in unstable angina and non-Q wave infarction. In 1996, the FRISC trial confirmed the value of LMWH (Dalteparine). However, this trial compared the LMWH with placebo. In 1997, the FRIC trial showed that dalteparine was equivalent to NFH. However, the ESSENCE and TIMI 11B trials reported the superiority of LMWH (Enoxaparine) over NFH in unstable angina and non-Q wave infarction. Compared with NFH, a significant 20% reduction in the composite criterion (death-non-fatal infarction) was observed with enoxaparine from the 2nd day up to day 43, without an increase in serious haemorrhagic complications. More recently, FRISC II showed the value and indicated the duration of treatment of LMWH, dalteparine, with respect to the chosen "invasive" or "non-invasive" strategies of revascularisation. The subcutaneous administration, absence of biological controls, the predictability of the anticoagulation and the better tolerance of the LMWH are powerful arguments in favour of their use in unstable angina and non-Q wave infarction. Thus, the LMWH have taken their place in the treatment of unstable coronary disease where the therapeutic arsenal is in constant evolution.

[Value of imaging in sarcoidosis]. / Apport de l'imagerie dans la sarcoïdose.

Imaging plays an important role in identifying thoracic, abdominal and neurological localizations of sarcoidosis as well as ENT and bone localizations. It contributes to disease detection and is helpful for diagnostic, prognostic and therapeutic decision making and useful for therapeutic monitoring. The chest x-ray is particularly important in the initial work-up and to follow well-tolerated disease. Other investigations, depending on the localization, are helpful to follow the course of severe or chronic sarcoidosis.

Comparison of the efficacy, safety, and onset of action of mizolastine, cetirizine, and placebo in the management of seasonal allergic rhinoconjunctivitis. MIZOCET Study Group.

BACKGROUND: Mizolastine is a potent and selective H1-receptor antagonist with additional anti-allergic properties. OBJECTIVE: The aim of this European multicenter, randomized, double-blind study was to compare the efficacy of mizolastine 10 mg (n = 122), cetirizine 10 mg (n = 125), and placebo (n = 128) once daily for 28 days in patients with seasonal allergic rhinoconjunctivitis (SAR), with focus on the onset of action. METHODS: Symptoms were evaluated by the investigator using a total symptom score (TS) and by the patient (first week). Responders (R) were patients with a TS decrease of at least 50%. Safety was assessed according to the spontaneous reporting of adverse events. RESULTS: Both mizolastine and cetirizine were effective in relieving the symptoms of SAR. After 7 days of treatment, the improvement in TS and responder's rate were significantly (P < .05) greater in patients treated with mizolastine (TS change versus baseline, mean +/- SD: -6.40 +/- 5.71; R: 55%) and cetirizine (TS change versus baseline: -6.24 +/- 5.24; R: 53%) than with placebo (TS change versus baseline: -4.11 +/- 5.91; R: 40%). Both drugs acted rapidly, within 2 hours of the first intake. During the first 3 days, mizolastine relieved symptoms more effectively than cetirizine, the difference being significant on the second (P = .027) and third (P = .050) day. Both mizolastine and cetirizine were well tolerated. CONCLUSION: Mizolastine 10 mg once daily is at least as effective as cetirizine in relieving symptoms of SAR, onset of action is rapid with clinical effect evident within 2 hours.

Von Willebrand factor in diabetic angiopathy.

Diabetes mellitus is a complex disease characterised by chronic hyperglycaemia responsible for complications affecting the kidneys, eyes, peripheral nerves and micro- and macrovascular systems. Von Willebrand factor (vWf), a multimeric glycoprotein mainly synthesised by endothelial cells, is involved in platelet adhesion and aggregation and acts as the carrier of coagulation factor VIII in plasma. Increased levels of vWf, reflecting activation of or damage to endothelial cells, have been described in association with atherosclerosis and diabetes. vWf appears to be a predictive marker of diabetic nephropathy and neuropathy, although not of retinopathy, which suggests that endothelial dysfunction precedes the onset of diabetic microangiopathy. This dysfunction could be especially involved in the pathogenesis of renal abnormalities of diabetes. vWf is not a predictive marker of macroangiopathy when diabetes is associated with atherosclerotic risk factors. In the presence of chronic diabetic complications, vWf levels are not associated with any grade of retinopathy but increase with the severity of nephropathy and would appear to be a risk factor for macrovascular mortality in these patients. The endothelial dysfunction of diabetes can generate atherosclerotic lesions responsible for damage to the arterial wall, atheroma and formation of platelet microaggregates. Concomitant with high vWf levels, other possible mechanisms of endothelial damage include reduced synthesis or release of nitric oxide, hyperglycaemic pseudohypoxia and protein kinase-C activation, increased synthesis of proteins bearing advanced glycosylation end-products or transforming growth factor-beta (TGF-beta) activation of coagulation and inhibition of fibrinolysis. At present, it is not known whether high vWf levels are inherent to the physiopathology of diabetes, nor whether diabetes induces endothelial dysfunction through other pathways. However, since angiopathy resulting from endothelial dysfunction is the main cause of morbidity and mortality in diabetic patients, appropriate therapy is necessary to reduce these complications. Glycaemic control seems to be insufficient to normalise plasma vWf, whereas a decrease can be obtained by ingestion of diets rich in oleic acid or by treatment with statins. Inhibition of the binding of vWf to the GPlba receptor by synthetic peptides, aurin tricarboxylic acid or monoclonal antibodies has been proposed to prevent the thrombosis induced by high levels of plasma vWf. Thus, vWf probably represents an interesting target for the inhibition of thrombosis in diabetes.

[Abnormality of hepatic perfusion in superior vena caval obstruction syndrome. A case report diagnosed by CT scan]. / Trouble de la perfusion hépatique au cours d'un syndrome cave supérieur. A propos d'un cas exploré en tomodensitométrie.

We describe a case of focal and intense contrast enhancement on hepatic CT due to superior vena caval obstruction and brachiocephalic vein obstruction. This phenomenon is explained by systemic portal venous shunting.

Pulmonary Wegener's granulomatosis: changes at follow-up CT.

The objective of this study was to assess the reversibility of pulmonary lesions in Wegener's granulomatosis using serial CT. We reviewed the follow-up CT scans of ten treated patients with confirmed Wegener's granulomatosis. The delay between the first evaluation before treatment and the second, on patients in clinical and biological remission, ranged from 6 to 54 months (mean 20.5 months). Follow-up CT showed a decrease in the extent of disease in all cases. Lesions disappeared completely, without scarring, in 4 of 4 ground-glass opacities, 25 of 36 nodules, and 4 of 9 pulmonary consolidations; they disappeared with residual scarring in 8 of 8 masses, 3 of 9 pulmonary consolidations, and 2 of 36 nodules. The majority of lesions disappear without scarring. Residual fibrosis may follow the occurence of masses and pulmonary consolidation. Computed tomography permits assessment of cicatricial lesions.

Sensitivity and long-term prognostic value of cardiac troponin-I increase shortly after percutaneous transluminal coronary angioplasty.

BACKGROUND: After successful coronary interventions, minor elevations of creatine kinase MB (CK-MB) identified a population with a worse long-term prognosis than that in patients without enzyme elevations. In that setting, cardiac troponin-I (cTn-I), a highly specific marker for myocardial injury, was considered for a small study; the results did not support the view that significant myocardial damage occurred during successful percutaneous transluminal coronary angioplasty (PTCA). HYPOTHESIS: The present study was designed to assess the rate of elevated values of cTn-I after successful PTCA and to determine its prognostic value. METHODS: CTn-I and CK-MB were measured in 44 patients before and daily for 3 days after PTCA. Two groups of patients were considered according to the presence or absence of elevated levels of cTn-I. The rate of free-event survival was estimated for the two groups using the Kaplan-Meier method and was compared with the log rank test. RESULTS: Globally, 36% of patients had an increase in cTn-I (normal values 0.35 ng/ml) and 9% had an increase in CK-MB, p = 0.002. The mean time to maximal enzyme level was 1.8 days for cTn-I and 2.2 days for CK-MB. Over a follow-up of 1375 +/- 416 days, 18% of patients experienced adverse events, and cTn-I did not identify a population of worse long-term prognosis. CONCLUSION: These results suggest that cTn-I is more sensitive than CK-MB in identifying minor myocardial damage after PTCA, but these elevated concentrations of cTn-I in the short-term aftermath of angioplasty do not seem to be a marker of worse long-term prognosis.

Comparative efficacy of a two-hour regimen of streptokinase versus alteplase in acute massive pulmonary embolism: immediate clinical and hemodynamic outcome and one-year follow-up.

OBJECTIVES: This study sought to compare the efficacy of 2-h regimens of alteplase and streptokinase in acute massive pulmonary embolism. The primary end point was immediate hemodynamic improvement, and secondary end points included early clinical efficacy and safety, as well as 1-year clinical outcome. BACKGROUND: Several thrombolytic regimens have been compared for the past 10 years in randomized studies, showing that 2-h infusion regimens of alteplase or urokinase lead to faster hemodynamic improvement than former 12- to 24-h administration protocols in acute massive pulmonary embolism. Many trials have focused on immediate hemodynamic and angiographic outcomes, but none has addressed long-term follow-up after thrombolysis. METHODS: Sixty-six patients with acute massive pulmonary embolism (Miller score > 17 and mean pulmonary artery pressure >20 mm Hg) were randomly assigned to receive either a 100-mg 2-h infusion of alteplase (n = 23) or 1.5 million IU of streptokinase over 2 h (n = 43). In both groups, heparin infusion was started at the end of thrombolytic infusion and adapted thereafter. Total pulmonary resistance was monitored over a 12-h period. Pulmonary vascular obstruction was assessed 36 to 48 h after thrombolytic therapy. One-year follow-up information included death, cause of death, recurrent pulmonary embolism, chronic thromboembolic pulmonary hypertension, stroke and bleeding. RESULTS: Both groups had similar baseline angiographic and hemodynamic characteristics of severity, with maintained cardiac output in 64 (97%) of 66 patients. The results (mean +/- SD) demonstrated that despite a faster total pulmonary resistance improvement observed at 1 h in the alteplase group compared with the streptokinase group (33+/-16% vs. 19 16%, p = 0.006), a similar hemodynamic efficacy was obtained at 2 h when both thrombolytic regimens were completed (38+/-18% vs. 31+/-19%). There was no significant difference in either pulmonary vascular obstruction at 36 to 48 h or bleeding complication rates. One-year event-free survival was similar in both groups, as most events were related to concomitant diseases. CONCLUSIONS: These results suggest that a 2-h regimen of streptokinase can be routinely used in patients with massive pulmonary embolism and maintained cardiac output without obviously compromising efficacy or safety.

[Initial evaluation of thoracic injuries. Comparison of pulmonary radiography and x-ray computed tomography]. / Bilan initial des traumatismes thoraciques. Comparaison de la radiographie pulmonaire et de la tomodensitométrie.

OBJECTIVES: To investigate the contribution of computed tomography scan (CTS) to the initial évaluation of chest trauma. PATIENTS AND METHODS: We carried out a two-year prospective study in all the chest trauma patients admitted to ICU. They underwent both Chest X-ray (CXR) and CTS within 24 jours of admission. CXR and CTS images were read by achieving a consensus between two radiologists who were unaware of the results of the other investigation. Then we compared these findings with the treatment received by the patients in the ICU. RESULTS: From July 1, 1991 through July 1, 1993, 56 patients were included (21 with conventional CTS and 35 with helicoidal CTS). CTS demonstrated a significant number of pleural (p < 0.001), parenchymatous (p < 0.001), and mediastinal (p < 0.01) lesions that escaped detection on CXR (CTS+/CXR- lesions). Thoracic drainage was done in 16 patients because of abnormalities CTS+/CXR- (p < 0.01); six patients with CTS+/CXR- pulmonary contusions received Pressure Positive Ventilation (p < 0.01); and four CTS+/CXR- lesions were treated surgically (p < 0.05). CONCLUSION: CTS adds significantly to the evaluation of chest trauma by allowing prompt, accurate assessment of lesions. In this study, over 50% of these lesions required specific treatment during the ICU stay.

Efficacy and safety of mizolastine in seasonal allergic rhinitis. The Rhinase Study Group.

BACKGROUND: Mizolastine is a new, nonsedating antihistamine under clinical investigation for treatment of allergic rhinitis and urticaria. OBJECTIVE: The purpose of this study was to determine the optimally active dose of once-daily mizolastine in seasonal allergic rhinitis. METHODS: This multicenter, double-blind, parallel study involved 494 patients randomly allocated to mizolastine (5, 10, or 15 mg) or placebo for 2 weeks. RESULTS: Physicians' assessments indicated the superiority of 10 and 15 mg mizolastine to placebo in reducing total symptom scores (P=.002), nasal scores (P=.004), and ocular scores (P=.007) at day 7. Patients' diaries showed a significant change from baseline in daily symptom scores as early as day 2 (P=.01) in 10- and 15-mg mizolastine groups in comparison to placebo, but this was not maintained throughout the study. No additional benefits were demonstrated during the second week of treatment in terms of efficacy. Adverse events were slightly more frequent in the 15-mg mizolastine group. CONCLUSION: This study conforms mizolastine is an effective and well tolerated antihistamine in the treatment of seasonal allergic rhinitis; 10 mg is the optimal dose.

The abdominal linea alba: an anatomo-radiologic and biomechanical study.

Traditionally, the linea alba represents the principal route of approach in abdominal surgery and in consequence it is the commonest site of incisional hernia. The aim of this study was to review its morphology and to study its mechanical parameters of resistance, deformation and elasticity in order to compare these with the prosthetic materials most often used in the treatment of incisional hernia. Forty fresh cadavers were dissected and tests with a dynamometer and "bursting strength tester" were performed on samples taken from the linea alba at three levels: supra-umbilical, subumbilical and umbilical. Forty abdomino-pelvic scans were analysed. The morphologic results allowed definition of diastasis of the rectus mm. in terms of subject age: below 45 years of age diastasis was considered as a separation of the two rectus mm. exceeding 10 mm above the umbilicus, 27 mm at the umbilical ring and 9 mm below the umbilicus; above 45 years of age the corresponding values were 15 mm, 27 mm and 14 mm respectively. In the biomechanical study the subumbilical region exhibited a coefficient of elasticity greater than that of the supra-umbilical portion, but no significant difference in resistance was found between the different parts studied. The biomechanical results are compared with the corresponding data for prosthetic materials.

[Hypersensitivity pneumopathies: x-ray computed tomographic aspects]. / Les pneumopathies d'hypersensibilité: aspects tomodensitométriques.

Chest radiographs and computed tomographic scans obtained from nineteen patients with hypersensitivity pneumonitis were reviewed retrospectively. Thirteen of them had a subacute form. Six of them had a chronic form. In subacute forms, CT scans were normal in two patients. In the 11 other cases, CT findings were ground glass attenuation (n = 10), nodules (n = 7) and linear opacities (n = 5). Ground glass attenuation was diffuse or patchy. Two patterns are quite suggestive of hypersensitivity pneumonitis: the association of micronodules and ground glass attenuation and the presence of hyperlucent secondary lobules within the ground glass. After cessation of exposure, CT showed a return to normal or improvement. Ground glass opacities, nodules and also linear opacities disappeared. CT scans were always abnormal in chronic forms. CT findings were linear opacities (n = 6), ground glass attenuation (n = 4), micronodules (n = 2) and cysts (n = 3).