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Objectives: Ventilator-associated pneumonia diagnosis remains a debatable topic. New definitions of ventilator-associated conditions involving worsening oxygenation have been recently proposed to make surveillance of events possibly linked to ventilator-associated pneumonia as objective as possible. The objective of the study was to confirm the effect of subglottic secretion suctioning on ventilator-associated pneumonia prevalence and to assess its concomitant impact on ventilator-associated conditions and antibiotic use., Design: Randomized controlled clinical trial conducted in five ICUs of the same hospital., Patients: Three hundred fifty-two adult patients intubated with a tracheal tube allowing subglottic secretion suctioning were randomly assigned to undergo suctioning (n = 170, group 1) or not (n = 182, group 2)., Main Results: During ventilation, microbiologically confirmed ventilator-associated pneumonia occurred in 15 patients (8.8%) of group 1 and 32 patients (17.6%) of group 2 (p = 0.018). In terms of ventilatory days, ventilator-associated pneumonia rates were 9.6 of 1,000 ventilatory days and 19.8 of 1,000 ventilatory days, respectively (p = 0.0076). Ventilator-associated condition prevalence was 21.8% in group 1 and 22.5% in group 2 (p = 0.84). Among the 47 patients with ventilator-associated pneumonia, 25 (58.2%) experienced a ventilator-associated condition. Neither length of ICU stay nor mortality differed between groups; only ventilator-associated condition was associated with increased mortality. The total number of antibiotic days was 1,696 in group 1, representing 61.6% of the 2,754 ICU days, and 1,965 in group 2, representing 68.5% of the 2,868 ICU days (p < 0.0001)., Conclusions: Subglottic secretion suctioning resulted in a significant reduction of ventilator-associated pneumonia prevalence associated with a significant decrease in antibiotic use. By contrast, ventilator-associated condition occurrence did not differ between groups and appeared more related to other medical features than ventilator-associated pneumonia.

Medical regulation represents an essential tool for emergency medical assistance. Even if it is essentially based on a 1964 law, our medical regulation is constantly evolving to meet the present needs and to follow the medical and technological advances. In this article, we shall outline its major components and evoke some long-awaited developments in the field of public health.

Chronic consumption of soda energizing caffeine has known a growing success. Its deleterious effects, however, are often ignored. We report a case of tetraparesis associated with chronic excessive consumption of cola. The development of muscle weakness is variable, resulting from a hyperpolarization of excitable membranes. The outcome is most often favorable after potassium supplementation and interruption of the offending beverage consumption. The mechanisms involved are multiple and involve both a leakage of fecal and urinary potassium and a potassium entry into the intracellular compartment. Other mechanisms related to caffeine are also involved. It therefore appears mandatory to assess the consumption of such beverages in the presence of hypokalemia and muscle weakness.

Arrhythmogenic right ventricular dysplasia is a rare, but not exceptional pathology combining the occurrence of potentially fatal arrhythmias with a gradual deterioration of the structure and function of the right ventricle. In this article, we discuss the etiopathology of the disease and emphasize the diagnostic approach.

The prolongation of life expectancy can only increase the proportion of elderly people in the future. The Emergency Departments being the main gateway to our hospitals, they will often have to admit such patients with their distinct characteristics. These individuals present with a more or less marked geriatric profile; it will be essential to determine their degree of frailty, a factor allowing to predict their survival and future level of autonomy. Evaluation tools have been developed to improve the management of these patients at important moments of their stay in the Emergency Department.

Heart failure in the elderly represents a major public health problem.In this population, the general objective of therapy, defined by current guidelines, does not differ from that proposed for younger patients: the aims are to decrease symptoms, to improve quality of life, to decrease hospitalizations, and to increase survival. However, in this category of patients, respect for autonomy and quality of life remains a priority, and requires a personalized approach because of the geriatric characteristics of many patients.

Methemoglobinemia is a rare disorder preferentially affecting children. The outcome may be dramatic when the disorder remains unidentified, however early recognition using unspecific exams allows prompt therapy. We report the case of a 14-month-old baby who presented with a sudden access of cyanosis resulting from acute methemoglobinemia. Careful investigation identified contamination of familial food by an excess of nitrates related to the use of well water from rural location.

Background: Few studies have examined the prevalence of alcohol and drug use in individuals with multiple sclerosis (MS). The current study sought to examine the prevalence and associated demographic, disease-related, and psychological correlates of substance use in an East Coast United States outpatient MS sample., Methods: 157 individuals with MS completed questionnaires prior to, during or after their visit with an MS neurologist. These questionnaires included: the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), CAGE, CAGE-Adapted to Include Drugs (CAGE-AID), Patient Health Questionnaire-9 item (PHQ-9), Beck Depression Inventory-Second Edition (BDI-II) and Hospital Anxiety and Depression Scale-Anxiety (HADS-A)., Results: On the AUDIT-C, 40% of individuals with MS met or exceeded the cutoff for excessive alcohol use. They were more highly educated and younger than non-drinkers. Utilizing the CAGE, 6% of the sample met criteria for a lifetime history of excessive alcohol use and men endorsed higher rates of alcohol use than women. Only a small portion of the sample endorsed a history of drug use (CAGE-AID, 4%). Drug use was associated with greater disability and depression symptoms, but lower self-reported anxiety., Conclusions: Current alcohol use was prevalent in this sample, and excessive use was associated with men, younger age, and more education. Reported drug use was minimal and associated with greater disability, more self-reported depression, but fewer anxiety symptoms., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Sudden cardiac arrest is an event associated with a very low survival rate. The latter is inversely proportional to the duration of the cardiovascular arrest. The chain of survival concept is a sequence of 4 events to be carried out as fast as possible with a view to ensure the patient's survival. This sequence consists of early access to and activation of the emergency medical system, early initiation of basic cardiopulmonary resuscitation, early defibrillation and early specialized care. The number of potential witnesses trained in Basic Life Support (BLS) does not guarantee an adequate basic resuscitation before the arrival of medical aid. In order to optimize the management of victims and callers, the concept of dispatching-assisted cardiopulmonary resuscitation based on a structured protocol has been implemented. The implementation of this plan to improve the quality of call handling required training and assessment of impacts on beneficiaries. The research datashow a reduction of the duration of cardiac arrest, an increase in resuscitation initiated by a witness, an improved survival rate, and a decreased stress and unanimous approval of dispatchers. Currently, the process is being improved and sustained.

Training methodology having emerged primarily over the last two decades, simulation in health care has arisen from the idea that students should never practice on the patient for their "first time". Simulation makes it possible to try out the errors and to repeat the skills over and over, in a reproducible way and in the most realistic possible environment, but with no harm to the patients, a risk socially intolerable. Simulation implies multiple methods from simple role-playing schemes to most powerful experiments on high-fidelity mannequins. In all cases, simulation implies a strictly codified structure: briefing, scenario, then debriefing. Indeed, debriefing represents the cornerstone of the teaching process allowing, both technical and non-technical skills acquisition through a work based on self-criticism. It should be noticed however that, although medical simulation has very clearly provided evidence of its effectiveness in skills acquisition, appropriate behaviours or application of algorithms, it has not demonstrated any benefit in terms of patients' care quality. Further research is therefore needed to validate this last assumption, which represents the very objective of any evolution in medicine.

Objectives: Early bystander cardiopulmonary resuscitation (CPR) is a key factor in improving survival from out-of-hospital cardiac arrest (OHCA). The ALERT (Algorithme Liégeois d'Encadrement à la Réanimation par Téléphone) algorithm has the potential to help bystanders initiate CPR. This study evaluates the effectiveness of the implementation of this protocol in a non-Advanced Medical Priority Dispatch System area., Methods: We designed a before and after study based on a 3-month retrospective assessment of victims of OHCA in 2009, before the implementation of the ALERT protocol in Liege emergency medical communication centre (EMCC), and the prospective evaluation of the same 3 months in 2011, immediately after the implementation., Results: At the moment of the call, dispatchers were able to identify 233 OHCA in the first period and 235 in the second. Victims were predominantly male (59%, both periods), with mean ages of 64.1 and 63.9 years, respectively. In 2009, only 9.9% victims benefited from bystander CPR, this increased to 22.5% in 2011 (p<0.0002). The main reasons for protocol under-utilisation were: assistance not offered by the dispatcher (42.3%), caller physically remote from the victim (20.6%). Median time from call to first compression, defined here as no flow time, was 253s in 2009 and 168s in 2011 (NS). Ten victims were admitted to hospital after ROSC in 2009 and 13 in 2011 (p=0.09)., Conclusion: From the beginning and despite its under-utilisation, the ALERT protocol significantly improved the number of patients in whom bystander CPR was attempted., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: Overcrowding in emergency departments (ED) leads to reductions in quality of care. Consequently, several different triage tools have been developed to prioritise patient intake. Differences in emergency medical services in different countries have limited the generalisation of pre-existing triage systems; for this reason, specific algorithms corresponding to local characteristics are needed. Accordingly, we developed a specific French-language triage system named Echelle Liégeoise d'Index de Sévérité à l'Admission (ELISA). This study tested its validity and efficiency., Methods: ELISA is a five-category nursing triage algorithm. Intrarater agreement was tested by comparing triage levels attributed to the same clinical scenarios at two different times. Interrater agreement was investigated by comparing triage categories attributed to clinical cases by different triage nurses. Finally, validity was estimated by studying the correlations between the triage ranking assigned by the nurse and actual resource consumption and patient outcome., Results: The distribution of the difference between nurse classification at the two times was statistically unrelated to which nurse carried out the evaluation. Regarding interrater agreement, assigned classifications were compared to the reference assignment. Cohen's κ coefficient revealed an almost perfect agreement between classification by nurses and the reference. Finally, statistical analysis revealed a strong relation between ELISA and the overall need for supplementary clinical testing. Outcomes were also significantly correlated with ELISA., Conclusions: The need for a specific, French-language triage tool in our ED led us to develop a new triage scale. This study demonstrates that the scale is a valid triage tool with high interrater and intrarater agreement and considerable efficiency.

Phone cardiopulmonary resuscitation (CPR) assists any cardiac arrest witness, previously trained or not, through standardized instructions given by phone. These instructions are intended to guide the bystander in checking for responsiveness, opening the airway and checking for adequate breathing, and to initiate chest compressions in case of apparent death. The "Algorithme Liégeois d'Encadrement à la Réanimation par Té1éphone" (ALERT) is an original phone CPR protocol helping the dispatchers to guide callers during the dispatcher's time window, between the beginning of the call and the Emergency Medical Services (EMS) arrival on scene. Its use has been demonstrated to increase the frequency and performance of bystanders' initial CPR efforts. Such improvement might increase the survival chances of out-of-hospital cardiac arrest victims (OOHCA).

Background: Compromised learning and cognitive fatigue are critical clinical features in multiple sclerosis., Objectives: This study was designed to determine the effect of repeated exposures within and across study visits on performance measures of learning and cognitive fatigue in relapsing-remitting multiple sclerosis (RRMS)., Methods: Thirty patients with RRMS and 30 controls were recruited. Using a burst measurement design (i.e. repeated assessments within and across study visits) the oral version of the Symbol Digit Modalities Test (SDMT) was administered three times during the baseline and two consecutive monthly follow-up visits for a total of nine test administrations. Learning was assessed within and across study visits whereas cognitive fatigue was assessed during the course of each test administration that was divided into three 30-second intervals., Results: Linear mixed-effect models revealed compromised learning within (95% CI: 2.6355 to 3.9867) and across (95% CI: 1.3250 to 3.1861) visits and worse cognitive fatigue (95% CI: -2.1761 to -0.1720) in patients with RRMS compared with controls. Among patients with RRMS, worse self-rated cognitive dysfunction predicted poor learning within (95% CI: -0.1112 to -0.0020) and across (95% CI: -0.0724 to -0.0106) visits., Conclusions: Burst design is optimal to study learning and cognitive fatigue. This methodology, using the SDMT or other time-efficient tests as outcome measures, can be successfully implemented in longitudinal studies and clinical trials.

Emergency departments are frequently overcrowded due to the imbalance between need and availability of care. It results that influx patients should be regulated by using a triage tool located at the entrance area. This process has been in development for almost 15 years.We propose a new algorithm of triage (ELISA or Liège Scale of severity index at admission) based on a five-score level of emergency from U1 (emergent) to U5 (non urgent). Such a stratification of the state of emergency is associated with a time-delay for the first medical contact (immediate to 120 min) and a corresponding track for providing optimal care (emergency care unit, B sector or bed, A sector or ambulatory and waiting room) which together fit the sorting for the right patient to the right resources in the right place at the right time. Our algorithm has a confident efficiency as evidenced by the comparison between initial score of emergency and patient's follow up (intensive care, hospital recovery and discharge).

Background: Valve dysfunction is a common cardiovascular pathology. Despite significant clinical research, there is little formal study of how valve dysfunction affects overall circulatory dynamics. Validated models would offer the ability to better understand these dynamics and thus optimize diagnosis, as well as surgical and other interventions., Methods: A cardiovascular and circulatory system (CVS) model has already been validated in silico, and in several animal model studies. It accounts for valve dynamics using Heaviside functions to simulate a physiologically accurate "open on pressure, close on flow" law. However, it does not consider real-time valve opening dynamics and therefore does not fully capture valve dysfunction, particularly where the dysfunction involves partial closure. This research describes an updated version of this previous closed-loop CVS model that includes the progressive opening of the mitral valve, and is defined over the full cardiac cycle., Results: Simulations of the cardiovascular system with healthy mitral valve are performed, and, the global hemodynamic behaviour is studied compared with previously validated results. The error between resulting pressure-volume (PV) loops of already validated CVS model and the new CVS model that includes the progressive opening of the mitral valve is assessed and remains within typical measurement error and variability. Simulations of ischemic mitral insufficiency are also performed. Pressure-Volume loops, transmitral flow evolution and mitral valve aperture area evolution follow reported measurements in shape, amplitude and trends., Conclusions: The resulting cardiovascular system model including mitral valve dynamics provides a foundation for clinical validation and the study of valvular dysfunction in vivo. The overall models and results could readily be generalised to other cardiac valves.

Objectives: Due to the recent interest in hands-only protocols for dispatcher-assisted cardiopulmonary resuscitation (CPR) and the lack of any validated algorithms in French, our primary objective was to evaluate a new French-language protocol in terms of its efficacy to help previously untrained volunteers in performing basic life support efforts of appropriate quality, and secondarily to investigate its potential utility in subjects with previous training., Methods: Untrained volunteers were recruited among adults in a public movie centre and previously trained volunteers among undergraduate nursing students. Participants were randomly assigned to 'phone CPR' versus 'no phone CPR' by drawing sets of envelopes. Primary outcome measures were the results of the Cardiff evaluation test; the secondary measures were global scoring of a complete 5min period of CPR, in a manikin model of cardiac arrest., Results: Out of 146 volunteers assessed for eligibility, 36 previously untrained candidates declined participation. 110 participants, distributed into four groups, completed the study: the previously untrained non-guided group (group A, n=30), the previously untrained guided group (group B, n=30), the previously trained non-guided group (group C, n=25) and the previously trained guided group (group D, n=25). Results of the Cardiff test and global evaluation of CPR performance revealed a significant improvement in group B as compared with group A, approaching the level of the group C. Previously trained guided bystanders had the best CPR scores, notably because of an improvement in the quality of airway management., Conclusion: When used by dispatchers, this new French-language algorithm offers the opportunity to help previously untrained bystanders initiate CPR. The same protocol may serve to guide volunteers with prior basic life support training to reach their best CPR performance., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

The hemolytic uremic syndrome (HUS) is rare and of guarded prognosis in adults. It expresses a renal thrombotic microangiopathy. We report the case of a young patient whose clinical presentation and exploration make a diagnosis of HUS likely. The atypical presentation provides an opportunity not only to discuss all diagnostic elements based on recent pathophysiological hypotheses, but also to highlight recommendations for the management of this severe disease.

The congenital long QT syndrome (LQTS) is a hereditary cardiac disease characterized by a prolongation of the QT interval > 440 ms at rest ECG associated with a high risk of ventricular arrhythmias (torsade de pointe). Clinical manifestations are syncope and sudden cardiac death. The implicated genes encode cardiac ion channel subunits or proteins involved in modulating ionic currents. The diagnosis of LQTS can be complex in borderline cases. Etiology, pathogenesis, diagnosis and treatment are discussed.

Epiploic appendagitis is the term used to describe the inflammation of an epiploic appendage. These small masses of fat distributed along the colon, from the caecum to the recto-sigmoid junction can inflammate by torsion, spontaneously or secondarily with the inflammation of an anatomical structure in the neighbourhood. Symptomatology may mimic retro-caecal appendicitis or diverticulitis and the diagnosis by CT avoids unnecessary surgery or hospitalization. Indeed, under conservative treatment by AINS and analgesics, symptomatology regresses in about five days. In this article, we relate the case of a patient with a typical clinical presentation, to remind the elements of this pathological entity.

Severe exacerbations of asthma can be life-threatening if not aggressively treated. Despite the publication of therapeutic guidelines developed by experts in this field and people education programs, early recognition and characterization of patients at risk for fatal asthma remain scarce. We report the case of a young lady suffering from acute exacerbation of asthma responsible for intensive care admission with long term mechanical ventilation due to the lack in initial appropriate care.

Aortic pseudo-aneurysm is a well-known late complication after surgical repair of aortic coarctation. We report two cases of pseudo-aneurysm of the aortic isthmus evidenced after previous surgical repair of congenital aortic coarctation. These clinical observations give us the opportunity to underline the importance of a specific lifelong medical follow-up for patients who have undergone such surgery.

We report the case of a 38-year-old man admitted at the emergency department for abdominal pain of abrupt onset. Computed tomographic examination revealed a spontaneous isolated dissection of the superior mesenteric artery and an anevrysm of the coeliac artery caused by the arcuate ligament. Outcome was favorable under conservative medical treatment and a three months follow-up was uneventful. This observation offers the opportunity to present recent insights concerning this pathology.

Drug self-poisoning is a common cause of admission in ED. Among various incriminated substances, paracetamol is often implicated and presents a severe toxicity. We briefly describe the epidemiology and physiopathology of paracetamol self-poisoning. We then clarify the diagnostic elements, thresholds of toxicity, indications for treatment and different available therapeutic guidelines.

The aim of this study was to test whether the simple ratio of right ventricular (RV) end-systolic pressure (Pes) to stroke volume (SV), known as the effective arterial elastance (Ea), provides a valid assessment of pulmonary arterial load in case of pulmonary embolism- or endotoxin-induced pulmonary hypertension. Ventricular pressure-volume (PV) data (obtained with conductance catheters) and invasive pulmonary arterial pressure and flow waveforms were simultaneously recorded in two groups of six pure Pietran pigs, submitted either to pulmonary embolism (group A) or endotoxic shock (group B). Measurements were obtained at baseline and each 30 min after injection of autologous blood clots (0.3 g/kg) in the superior vena cava in group A and after endotoxin infusion in group B. Two methods of calculation of pulmonary arterial load were compared. On one hand, Ea provided by using three-element windkessel model (WK) of the pulmonary arterial system [Ea(WK)] was referred to as standard computation. On the other hand, similar to the systemic circulation, Ea was assessed as the ratio of RV Pes to SV [Ea(PV) = Pes/SV]. In both groups, although the correlation between Ea(PV) and Ea(WK) was excellent over a broad range of altered conditions, Ea(PV) systematically overestimated Ea(WK). This offset disappeared when left atrial pressure (Pla) was incorporated into Ea [Ea * (PV) = (Pes - Pla)/SV]. Thus Ea * (PV), defined as the ratio of RV Pes minus Pla to SV, provides a convenient, useful, and simple method to assess the pulmonary arterial load and its impact on the RV function.

Aims: To assess the ability of Listeria monocytogenes to form biofilm on different food-contact surfaces with regard to different temperatures, cellular hydrophobicity and motility., Methods and Results: Forty-four L. monocytogenes strains from food and food environment were tested for biofilm formation by crystal violet staining. Biofilm levels were significantly higher on glass at 4, 12 and 22 degrees C, as compared with polystyrene and stainless steel. At 37 degrees C, L. monocytogenes produced biofilm at significantly higher levels on glass and stainless steel, as compared with polystyrene. Hydrophobicity was significantly (P < 0.05) higher at 37 degrees C than at 4, 12 and 22 degrees C. Thirty (68.2%) of 44 strains tested showed swimming at 22 degrees C and 4 (9.1%) of those were also motile at 12 degrees C. No correlation was observed between swimming and biofilm production., Conclusions: L. monocytogenes can adhere to and form biofilms on food-processing surfaces. Biofilm formation is significantly influenced by temperature, probably modifying cell surface hydrophobicity., Significance and Impacts of the Study: Biofilm formation creates major problems in the food industry because it may represent an important source of food contamination. Our results are therefore important in finding ways to prevent contamination because they contribute to a better understanding on how L. monocytogenes can establish biofilms in food industry and therefore survive in the processing environment.

In acute pulmonary embolism, right ventricular (RV) failure may result from exceeding myocardial contractile resources with respect to the state of vascular afterload. We investigated the adaptation of RV performance in a porcine model of progressive pulmonary embolism. Twelve anesthetized pigs were randomly divided into two groups: gradual pulmonary arterial pressure increases by three injections of autologous blood clot (n=6) or sham-operated controls (n=6). Right ventricular pressure-volume (PV) loops were recorded using a conductance catheter. Right ventricular contractility was estimated by the slope of the end-systolic PV relationship (Ees). After load was referred to as pulmonary arterial elastance (Ea) and assessed using a four-element Windkessel model. Right ventricular-arterial coupling (Ees/Ea) and efficiency of energy transfer (from PV area to external mechanical work [stroke work]) were assessed at baseline and every 30 min for 4 h. Ea increased progressively after embolization, from 0.26+/-0.04 to 2.2+/-0.7 mmHg mL(-1) (P<0.05). Ees increased from 1.01+/-0.07 to 2.35+/-0.27 mmHg mL(-1) (P<0.05) after the first two injections but failed to increase any further. As a result, Ees/Ea initially decreased to values associated with optimal SW, but the last injection was responsible for Ees/Ea values less than 1, decreased stroke volume, and RV dilation. Stroke work/PV area consistently decreased with each injection from 79%+/-3% to 39%+/-11% (P<0.05). In response to gradual increases in afterload, RV contractility reserve was recruited to a point of optimal coupling but submaximal efficiency. Further afterload increases led to RV-vascular uncoupling and failure.

Introduction: Functional residual capacity (FRC) measurement is now available on new ventilators as an automated procedure. We compared FRC, static thoracopulmonary compliance (Crs) and PaO2 evolution in an experimental model of acute respiratory distress syndrome (ARDS) during a reversed, sequential ramp procedure of positive end-expiratory pressure (PEEP) changes to investigate the potential interest of combined FRC and Crs measurement in such a pathologic state., Methods: ARDS was induced by oleic acid injection in six anesthetised pigs. FRC and Crs were measured, and arterial blood samples were taken after induction of ARDS during a sequential ramp change of PEEP from 20 cm H2O to 0 cm H2O by steps of 5 cm H2O., Results: ARDS was responsible for significant decreases in FRC, Crs and PaO2 values. During ARDS, 20 cm H2O of PEEP was associated with FRC values that increased from 6.2 +/- 1.3 to 19.7 +/- 2.9 ml/kg and a significant improvement in PaO2. The maximal value of Crs was reached at a PEEP of 15 cm H2O, and the maximal value of FRC at a PEEP of 20 cm H2O. From a PEEP value of 15 to 0 cm H2O, FRC and Crs decreased progressively., Conclusion: Our results indicate that combined FRC and Crs measurements may help to identify the optimal level of PEEP. Indeed, by taking into account the value of both parameters during a sequential ramp change of PEEP from 20 cm H2O to 0 cm H2O by steps of 5 cm H2O, the end of overdistension may be identified by an increase in Crs and the start of derecruitment by an abrupt decrease in FRC.

Objective: Virulent airborne diseases can be a real burden to a nation's health system. The most recent threat is the fear of a mutation-induced H5N1-influenza pandemic. We studied whether Belgian hospitals are able to deal with H5N1-influenza infected patients in the case of a pandemic. Many patients, including children, may require artificial ventilation within 48 h after admission., Methods: A survey aimed at determining 'availability and preparedness' was sent by e-mail to the different Belgian Emergency Departments., Results and Discussion: Sixty-five hospitals were finally included. The amount of patients being potentially admitted is limited, owing to the reduced number of intensive care beds equipped with automatic ventilators. Furthermore, the number of available intensive care beds for children is still lower than for adult patients. The number of mortuary places, in the case of a catastrophe, is also insufficient. Although most hospitals set up a disaster plan on H5N1, there are only limited stocks of antiviral medication to protect the hospital staff in the acute phase. A separate triage area is only available in a limited number of hospitals. We conclude that Belgian hospitals and emergency departments are not equipped to deal with potential pandemic situations.

Aims: Pulmonary hypertension, a marker of poor prognosis in heart failure, may develop or increase during exercise. We sought to examine the determinants of pulmonary hypertension at rest and during exercise in heart failure patients., Methods and Results: Forty-six patients with left ventricular (LV) dysfunction (ejection fraction: 30 +/- 6%) underwent a semi-recumbent, incremental bicycle exercise Doppler echocardiography. LV systolic and diastolic function, pulmonary artery systolic pressure (PASP), functional mitral regurgitation (MR), and left atrial volume were quantified at rest and during exercise. Wide changes in PASP at exercise were unrelated to PASP at rest (r = 0.12). Independent predictors of PASP at rest were left atrial volume (P = 0.006), E-wave velocity (P = 0.02), mitral tenting area (P = 0.005), and mitral effective regurgitant orifice (ERO) (P = 0.02). The incidence of dyspnoea was similar in patients with and without moderately severe pulmonary hypertension at baseline. At peak exercise, LV ejection fraction (P = 0.03) and mitral ERO (P = 0.008) were independently associated with PASP. Patients with a larger exercise increase in PASP (>60 mmHg) interrupted frequently exercise for dyspnoea (70 vs. 27%; P = 0.04). A larger rise in mitral regurgitant volume during exercise emerged as the single determinant of exercise-induced increases in PASP., Conclusion: In patients with HF, left atrial volume, mitral deformation, and mitral regurgitant orifice correlated with pulmonary pressure at rest, whereas dynamic MR and limited contractile reserve correlated with pulmonary pressure at exercise. The magnitude of pulmonary pressure during exercise in these patients mainly depends on dynamic MR.

Evaluation of the aid of an emergency mobile unit to transfer monitorized patients to a University hospital, in the political context of regional care network offering highly qualified but restricted tertiary area centres, and an open prospective study conducted over the 5 first months in 2006. The call regulation was assessed by the emergency physician of the transfer team and all missions were concluded with an evaluating report. An amount of 197 requests were taken into account from which 80 % were addressed between 8 am and 8 pm. The mean average time interval for missions was 59 minutes (base to base) and the distance covered was 20.7 km as a mean. In essence, indications for medical secondary transfer regarded patients in need for acute coronary care (42.6%), specific intensive care (26.4%) and neurosurgical interventions (19.3%). We noted that endotracheal intubation occurred in only one case. Mortality during such a transfer activity was absent. Medical transfer unit allows the development of specific high qualified network resources owing to the secondary addressee of patients. However, the weak incidence of complication questions the practice of systematic medical accompanying during such transfers.

Although reperfusion after coronary occlusion is mandatory for myocardial salvage, reperfusion may trigger a cascade of harmful events (reperfusion injury) adding to myocardial injury. We investigated effects of reperfusion on left ventricular (LV) haemodynamics and ventriculo-arterial (VA) coupling in pigs following acute myocardial ischaemia induced by coronary artery occlusion. Experiments were performed in six animals, with measurements of cardiac and arterial function at baseline, after 60 min of ischaemia (T60) and after 2 (T180) and 4 h of reperfusion (T300). Ventriculo-arterial coupling was assessed using the ventriculo-arterial elastance ratio of paper, as well as using a 'stiffness coupling' and 'temporal coupling' index. Reperfusion following ischaemia (T180 versus T60) induced a progressive decline in cardiovascular function, evidenced by a decrease in mean arterial blood pressure, cardiac output and ejection fraction which was not restored at T300. Although reperfusion also induced an increase in slope of the end-systolic pressure-volume relationship (ESPVR), the ESPVR curve shifted to the right, associated with a depression of contractile function. Histology demonstrated irreversible myocardial damage at T300. The ventriculo-arterial elastance ratio and the 'stiffness coupling' index were unaffected throughout the protocol, but the 'temporal coupling' parameter indicated a relative shift between heart period and the time constant of the arterial system. It is unlikely that these alterations are attributable to ischaemic injury alone. The combination of both the stiffness and temporal coupling index may provide more information when studying ventriculo-arterial coupling than the more commonly used ventricular end-systolic stiffness/effection arterial elastance (E(es)/E(a)) ratio.

Objective: To confirm in vivo the hypothesis that hemofiltration with a large pore membrane can achieve significant cytokine clearance., Method: We used a well-known animal model of endotoxinic shock (0.5 mg/kg of lipopolysaccharide from Escherichia Coli over a period of 30 mins). Six pigs were hemofiltrated for 3 hours with a large pore membrane (78 A pore, 80 kDa cut off) (Sureflux FH 70, Nipro, Osaka, Japan). The ultrafiltration rate was 45 ml/kg/min. Samples were taken from arterial, venous line and in the ultrafiltrate at T120 and T240. We measured concentrations of interleukin 6, interleukin 10 and albumin., Results: At T120 and T240, the IL-6 clearances were 22 +/- 7 and 15 +/- 3 ml/min, respectively. The IL-6 sieving coefficients were 0.97 and 0.7 at T120 and T240, respectively. At T120 and T240, the IL-10 clearances were 14 +/- 4 and 10 +/- 7 ml/min, respectively. The sieving coefficients were 0.63 and 0.45 at T120 and T240, respectively. The concentrations of IL-6 and IL-10 were the same at T0 and T240. At T60 and T240, the plasmatic albumin concentrations were 24 +/- 4 g/L and 23 +/- 4 g/L, respectively (p = 0.13)., Conclusions: In this animal model of endotoxinic shock, we confirm the high cytokine clearance observed when hemofiltration is applied to a large pore membrane. The loss of albumin seems negligible. The impact of such clearances on hemodynamic stability and survival remains to be proved.

The occurrence of an acute myocardial infarction after non-penetrating chest trauma is an extremely rare complication. We report a case of dissection of the left anterior descending artery in a 43 year old man after being punched in the chest. Using data from a literature search relish revealed 76 cases; we review the characteristics of the pathology and its incidence. We also characterize its etiology, anatomy and path physiology. We then consider the diagnostic and therapeutic implications.

Hemodynamic improvement in patients suffering from both septic shock and renal failure who received hemofiltration suggested that an extrarenal epuration technique could be of interest in patients with septic shock alone. However, most of the studies using continuous venovenous hemofiltration (CVVH) in this setting evidenced neither cytokine clearance nor significant reduction in their plasma level. Lack of significant clearance was explained in part by the small size of the membrane pores. Therefore, we investigated the effects of large-pore membrane hemofiltration (LPHF) during endotoxic shock in pigs on interleukin 6 (IL-6) and interleukin 10 (IL-10) clearances, and on right ventricular (RV)-vascular coupling. Thirteen anesthetized healthy pigs weighing 20-30 kg were divided into two groups. In the Endo group (n = 6), the pigs received a 0.5-mg/kg endotoxin infusion over a period of 30 mins from T0 to T30. In the EndoHF group (n = 7), LPHF (cutoff = 80 kDa) and an ultrafiltration rate of 45 mL/kg/h were started 30 mins after the end of the endotoxin infusion, from T60 to T240. In this model of porcine endotoxic shock, LPHF was responsible for a significant clearance of IL-6 (20 mL/min) and Il-10 (14 mL/min), and for an improvement in RV-vascular coupling.

Retroperitoneal fibrosis is an uncommon inflammatory disease which is characterized by the development of a fibrous process that surrounds the major vessels and organs located within the retroperitoneum. Isolated as an idiopathic expression or associated with several other diseases in its secondary form, retroperitoneal fibrosis remains relatively of rare occurrence and as a result, is devoid of either diagnostic or therapeutic definitive recommendations. We report the observation of one case admitted in the emergency room for abdominal pain induced by left hydronephrosis. Radiographic exploration with contrast-enhanced studies evidenced retroperitoneal fibrosis causing left ureteric obstruction. Therapeutic approach was based on corticosteroids and ureteral drainage which prevented recurrence while fibrosis was almost reversed six months later.

In this paper we review the current knowledge on pulmonary hypertension (PH) occurring in COPD. PH is defined as a mean pulmonary arterial pressure at rest greater than 20 mmHg measured by right heart catheterisation. PH is usually present during exercise before appearing at rest. PH in COPD increases the risk of hospitalisation and darkens the disease prognosis. Chronic hypoxemia is the major contributor to PH, but remodelling of arterial wall and mechanical factors such as hyperinflation also play a role. Transthoracic echocardiography is the most useful non invasive investigation, but right heart catheterisation is necessary to ascertain the diagnosis. Long term 02 supplementation is the basis of the treatment while vasodilatators may worsen hypoxemia.

Purpose: To retrospectively evaluate pulmonary artery (PA) clot load scores and computed tomographic (CT) cardiovascular parameters as predictors of mortality in patients with severe pulmonary embolism (PE)., Materials and Methods: Institutional review board approval was obtained with waiver of informed consent. A total of 82 consecutive patients (42 women, 40 men; mean age+/-standard deviation, 61 years+/-15) were admitted to the intensive care unit for PE-related conditions and were evaluated by using CT pulmonary angiography. Two independent readers who were blinded to clinical outcome quantified PA clot load by using four scoring systems. Cardiovascular measurements included right ventricular (RV) and left ventricular (LV) short-axis measurements; RV short axis to LV short axis (RV/LV) ratios; main PA, ascending aorta, azygos vein, and superior vena cava diameters; and main PA diameter to aorta diameter ratios. Reflux of contrast medium into the inferior vena cava, leftward bowing of the interventricular septum, pleural or pericardial effusion, pulmonary consolidation, infarct, platelike atelectasis, and mosaic ground-glass opacity were also recorded. Results were correlated with patient outcome during hospital stay by using the Wilcoxon rank sum and chi2 tests., Results: Twelve patients died within 1-14 days. RV and LV short axis; RV/LV ratio; azygos vein, superior vena cava, and aorta diameters; and contrast medium reflux into the inferior vena cava were significantly different between survivors and nonsurvivors (P<.05). No significant relationship was found between PA clot load and mortality rate. RV/LV ratio and azygos vein diameter allowed correct prediction of survival in 89% of patients (P<.001)., Conclusion: RV/LV ratio and azygos vein diameter are predictors of mortality in patients with severe PE., (Copyright (c) RSNA, 2006.)

Recent international guidelines about emergency situations (ILCOR / ERC) pointed to the need of the whole "chain of survival". ALS, Advanced Life Support (the last and "medical" part of the chain ) is important and influences survival rate. If no doubt exists about "what" and "when" to do in such situations, there is no consensus in industrialized countries about "who" should be in charge of such out-of-hospital acute diagnosis and treatment: emergency physicians, emergency nurses, emergency medical technicians (EMT), other "new" professionals ? ... A description of the MICU system in Belgium is given.

Aims: To investigate whether BM-573 (N-tert-butyl-N'-[2-(4'-methylphenylamino)-5-nitro-benzenesulfonyl]urea), an original combined thromboxane A2 synthase inhibitor and receptor antagonist, prevents reperfusion injury in acutely ischemic pigs., Methods: Twelve animals were randomly divided in two groups: a control group (n = 6) intravenously infused with vehicle, and a BM-573-treated group (n = 6) infused with BM-573 (10 mg kg(-1) h(-1)). In both groups, the left anterior descending (LAD) coronary artery was occluded for 60 min and reperfused for 240 min. Either vehicle or BM-573 was infused 30 min before LAD occlusion and throughout the experiment. Platelet aggregation induced by arachidonic acid ex vivo measured was prevented by BM-573., Results: In both groups, LAD occlusion decreased cardiac output, ejection fraction, slope of stroke work--end-diastolic volume relationship, and induced end-systolic pressure-volume relationship (ESPVR) rightward shift, while left ventricular afterload increased. Ventriculo-arterial coupling and mechanical efficiency decreased. In both groups, reperfusion further decreased cardiac output and ejection fraction, while ESPVR displayed a further rightward shift. Ventriculo-arterial coupling and mechanical efficiency remained impaired. Area at risk, evidenced with Evans blue, was 33.2+/-3.4% of the LV mass (LVM) in both groups, and mean infarct size, revealed by triphenyltetrazolium chloride (TTC), was 27.3+/-2.6% of the LVM in the BM-573-treated group (NS). Histological examination and immunohistochemical identification of desmin revealed necrosis in the anteroseptal region similar in both groups, while myocardial ATP dosages and electron microscopy also showed that BM-573 had no cardioprotective effect., Conclusions: These data suggest that BM-573 failed to prevent reperfusion injury in acutely ischemic pigs.

Computed tomographic (CT) pulmonary angiography has been established as a first-line diagnostic technique in patients suspected of having pulmonary embolism. Risk stratification is important in patients with pulmonary embolism because optimal management, monitoring, and therapeutic strategies depend on the prognosis. Acute right-sided heart failure is known to be responsible for circulatory collapse and death in patients with severe pulmonary embolism. Acute right-sided heart failure can be assessed at CT pulmonary angiography by measuring the dimensions of right-sided heart cavities or upstream venous structures, such as the superior vena cava or azygos vein. The magnitude of pulmonary embolism can be calculated at CT pulmonary angiography by applying angiographic scores adapted for CT (Miller and Walsh scores) or dedicated CT scores (Qanadli and Mastora scores). The advent of CT pulmonary angiography performed with electrocardiographic gating permits new advances in assessment of acute right-sided heart failure, such as measurement of the ventricular ejection fraction. Although such findings may be useful for assessment of treatment effectiveness, their effect on prognosis in patients with severe pulmonary embolism is debated in the literature., ((c) RSNA, 2006.)

The aim of our study was to evaluate the effects of thromboxane A2 (TXA2) agonist, U-46619, on systemic circulatory parameters in the pigs before and after administration of a novel TXA2 receptor antagonist and synthase inhibitor (BM-573). Twelve anesthetized pigs were randomly assigned in two groups: in Ago group (n=6), the animals received six consecutive injections of U-46619 at 30 min interval, while in Anta group (n=6) they received an increasing dosage regimen of BM-573 10 min before each U-46619 injection. The effects of each dose of BM-573 on ex vivo platelet aggregation induced by arachidonic acid, collagen or ADP were also evaluated. Vascular properties such as characteristic impedance, peripheral resistance, compliance, arterial elastance were estimated using a windkessel model. Intravenous injections of 0.500 mg/ml of BM-573 and higher doses resulted in a complete inhibition of platelet aggregation induced by arachidonic acid. In the same conditions, BM-573 completely blocked the increase of arterial elastance, and stabilized both mean aortic blood pressure and mean systemic blood flow. In conclusion, BM-573 could therefore be a promising therapeutic approach in pathophysiological states where TXA2 plays a main role in the increase of vascular resistance like in pathologies such as systemic hypertension.