[Medical simulation as a tool in the training of perinatal professionals]. / La simulation médicale comme outil dans la formation des professionnels de la périnatalité.

Though technology plays an increasingly important role in modern health systems, human performance remains a major determinant of safety, effectiveness and efficiency of patient care. This is especially true in the delivery room. Thus, the training of professionals must aim not only for the acquisition of theory and practical skills on an individual basis, but also for the learning of teamwork systematically. Training health professionals with simulation enhances their theoretical knowledge and meets formal requirements in literacy, technical skills and communication. Therefore, we intend to explore how, in perinatal care, training with simulation is actually a key teaching tool in initial education and in perpetuation of knowledge. We will approach three main aspects: individual, collective (team) and the impact of simulation in medical practice. The choice of this educational strategy improves the clinical skills that are required for optimal performance in complex, unpredictable and high-stake environments such as the delivery room. Nonetheless, the long term clinical impact of simulation and whether it's modalities, technical or not, are beneficial to the mother and the newborn are areas still to be explored.

[Hysteroscopic septoplasty: after miscarriages?]. / Faut-il attendre les accidents obstétricaux pour sectionner les cloisons utérines ?

OBJECTIVE: To assess reproductive outcome of women affected by septate uterus after surgical correction. PATIENTS AND METHODS: It is a retrospective study. The setting is a French university hospital. Surgery was performed on 66 patients between 2000 and 2010. Hysteroscopic metroplasty was performed in every group once the diagnosis was made. There were two groups: 35 patients affected by septate uterus had past history of miscarriages, preterm and term deliveries. Thirty-six patients had never been pregnant. RESULTS: In the group of 35 patients with a previous obstetric history, the rate of miscarriages was 57.1% before surgery and 10% after surgery. There was a significant gain of live birth ratio of 55% among women being pregnant after surgery compared to women being pregnant before surgery. For patients with no pregnancy before surgery, obstetrical results are the following ones: miscarriages 25.9%, preterm deliveries 11% and term deliveries 59.3%. DISCUSSION AND CONCLUSION: Hysteroscopic septoplasty is an easy technique with few complications in our study. Hysteroscopic septoplasty is strongly recommended after recurrent miscarriages or premature deliveries. We use to propose surgery to every patient affected by septate uterus, even if they have never been pregnant.

Density estimation of a biomedical variable subject to measurement error using an auxiliary set of replicate observations.

Correcting for measurement error when estimating the density of a routinely collected biomedical variable is an important issue when describing reference values for both healthy and pathological states. The present work addresses the problem of estimating the density of a biomedical variable observed with measurement error without any a priori knowledge on the error density. Assuming the availability of a sample of replicate observations, either internal or external, which is generally easily obtained in clinical settings, we propose an estimator based on the non-parametric deconvolution theory with an adaptive procedure for cutoff selection, the replicates being used for an estimation of the error density. We illustrate this approach in two applicative examples: (i) the systolic blood pressure distribution density, using the Framingham Study data set, and (ii) the distribution of the timing of onset of pregnancy within the female cycle, using ultrasound measurements in the first trimester of pregnancy.

Myocardial perfusion imaging and cardiac events in a cohort of asymptomatic patients with diabetes living in southern France.

AIMS: To assess the association between abnormal stress myocardial perfusion imaging (MPI) and cardiac events (CE) in asymptomatic patients with diabetes and with > or = 1 additional risk factor. Predictors of abnormal stress MPI were also evaluated. METHODS: Four hundred and forty-seven consecutive patients who underwent stress MPI were prospectively followed for 2.1 [0.5-4.1] years for the subsequent occurrence of hard CE (myocardial infarction and sudden or coronary death) and soft CE (unstable angina and ischaemic heart failure requiring hospitalization). Re-vascularization procedures performed as a result of the screening protocol were not included in the analysis. RESULTS: Follow-up was successful in 419 of 447 patients (94%), of whom 71 had abnormal MPI at baseline. Medical therapy was intensified in all subjects and especially in those with abnormal MPI. Twenty-three patients with abnormal MPI underwent a re-vascularization procedure. CEs occurred in 14 patients, including six of 71 patients (8.5%) with abnormal MPI and eight of 348 patients (2.3%) with normal MPI (P < 0.005). Only two patients developed a hard CE and 12 a soft CE. In multivariate analysis, abnormal MPI was the strongest predictor for CEs [odds ratio (OR) (95% CI) = 5.6 (1.7-18.5)]. Low-density lipoprotein cholesterol > or = 3.35 mmol/l [OR (95% CI) = 7.3; 1.5-34.7] and age > median [OR (95% CI) = 6.0 (1.2-28.6)] were additional independent predictors for CE. The independent predictors for abnormal MPI were male gender, plasma triglycerides > or = 1.70 mmol/l, creatinine clearance < 60 ml/min and HbA1c > 8%, with male gender the strongest [OR (95% CI) = 4.0 (1.8-8.8)]. CONCLUSIONS: Asymptomatic patients with diabetes in this study had a very low hard cardiac event rate over an intermediate period. This could be explained by the effects of intervention or by the low event rate in the background population. Randomized studies of cardiac heart disease screening are required in asymptomatic subjects with diabetes to determine the effectiveness of this intervention.

Accuracy and precision of perfusion lung scintigraphy versus 133Xe-radiospirometry for preoperative pulmonary functional assessment of patients with lung cancer.

PURPOSE: This study sought to determine whether (133)Xe-radiospirometry (XRS) successfully selects patients able to undergo lung resection without postoperative respiratory complications and whether perfusion lung scintigraphy (PLS) is likely to provide a similar selection of patients for certain tumour stages. METHODS: Two hundred and eighty-four patients with resectable lung cancer underwent preoperative assessment of postoperative forced expiratory volume in 1 s (FEV(1)) by XRS and PLS. Correlations, Bland and Altman analysis and contingency tables were used to analyse the difference between the two predictive techniques. RESULTS: One hundred and sixty patients underwent lung resection on the basis of XRS preoperative testing only. None of them developed respiratory insufficiency. Despite a close correlation, the limits of agreement between predicted FEV(1) by XRS and PLS exceeded +/-0.3 l/s. For tumour stages T1Nx and T2N0, PLS underestimated postoperative FEV(1) whereas it overestimated this parameter for stage III. CONCLUSION: XRS accurately selects patients able to undergo lung resection without postoperative pulmonary insufficiency. The agreement between XRS and PLS is unacceptable. When only PLS is available, higher thresholds for patients with stage III cancers and lower thresholds for those with stage I cancers should be used to decide on operability.

Routine measurements of left and right ventricular output by gated blood pool emission tomography in comparison with thermodilution measurements: a preliminary study.

The aim of this preliminary study was to evaluate the accuracy of left and right ventricular output computed from a semi-automatic processing of tomographic radionuclide ventriculography data (TRVG) in comparison with the conventional thermodilution method. Twenty patients with various heart diseases were prospectively included in the study. Thermodilution and TRVG acquisitions were carried out on the same day for all patients. Analysis of gated blood pool slices was performed using a watershed-based segmentation algorithm. Right and left ventricular output measured by TRVG correlated well with the measurements obtained with thermodilution (r = 0.94 and 0.91 with SEE = 0.38 and 0.46 l/min, respectively, P < 0.001). The limits of agreement for TRVG and thermodilution measurements were -0.78-1.20 l/min for the left ventricle and -0.34-1.16 l/min for the right ventricle. No significant difference was found between the results of TRVG and thermodilution with respect to left ventricular output (P = 0.09). A small but significant difference was found between right ventricular output measured by TRVG and both left ventricular output measured by TRVG (mean difference = 0.17 l/min, P = 0.04) and thermodilution-derived cardiac output (mean difference = 0.41 l/min, P = 0.0001). It is concluded that the watershed-based semi-automatic segmentation of TRVG slices provides non-invasive measurements of right and left ventricular output and stroke volumes at equilibrium, in routine clinical settings. Further studies are necessary to check whether the accuracy of these measurements is good enough to permit correct assessment of intracardiac shunts.

[Hyperammonemia and decrease of growth and nocturnal locomotion in rats with portal stricture and uremia]. / Hyperammoniémie et diminution de la croissance et de la locomotion nocturne chez le rat avec stricture portale et urémie.

In order to make clearer the pathogenesis of hepatic coma, the clinical tolerance of progressive levels of chronic hyperammonemia were studied in the rat. Increases of blood ammonia in the range of 200 to 600 micrograms/dl were produced within 4 weeks by stricture of the portal vein associated with progressive rises in blood urea resulting from reduction of the renal mass and/or addition of urea to the food. The portal stricture produces a collateral circulation allowing a hepatic bypass of portal blood and the ammonia level of this blood is proportional to the amount of circulating and alimentary urea hydrolyzed in the digestive tract. Only the highest hyperammonemias were associated with decreased nocturnal locomotion of the rats and decrease in the growth rate. The latter was correlated with the ammonia levels. No animal presented signs of coma. These results suggest a good cerebral tolerance by the rat of important chronic hyperammonemias which however seem to have an anorexic effect.

[Breakfast tolerance test: application to the detection of gestational diabetes]. / Le test de tolérance au petit déjeuner: application au dépistage du diabète gestationnel.

There is general agreement that diagnosis of diabetes mellitus in pregnancy is requisite but the means of achieving it are still under discussion. The plasma glucose, insulin and C peptide responses to an oral glucose tolerance test were compared with the intravenous glucose tolerance test and a standardized breakfast tolerance test in 26 pregnant women, in order to define a simple diagnostic criterion for gestational glucose intolerance. The results of the oral glucose tolerance test distinguished between a group of 19 normal women and a group of 7 diabetic women with abnormal glucose tolerance tests. The breakfast tolerance test used (84 g carbohydrates, 22,6 g protein, 9,4 g fat, 690 calories) was followed by blood glucose modifications very similar to those observed with the oral glucose tolerance test, but the insulin response was significantly greater. The consistency between the breakfast tolerance and intravenous glucose tolerance tests was confirmed by the existence of correlations between the glucose area of the breakfast tolerance test and the coefficient K in the two groups studied. Our results suggest that the breakfast tolerance test could be as sensitive as the oral glucose tolerance test for detecting glucose intolerance; the most discriminative glycemic value appeared to be that at the 180 th minute, usually under 1 g/l in the normal pregnant women. This test could be proposed as an easy and economic method for diagnosing gestational diabetes. These preliminary results require confirmation by a study in a larger population.

[Renal origin of hyperammonemia induced by an high-protein diet in normal rats or those with portal stricture]. / Origine rénale de l'hyperammoniémie provoquée par un régime hyperprotidique chez le rat normal ou porteur d'une stricture portale.

Hyperammonemia is observed in high protein diet fed cirrhotic and is thought to be related to an increased intestinal ammoniagenesis. We studied this problem in control rats and rats with a portal stricture and portal systemic shunts given a high protein or a standard diet. In those animals the systemic, portal and renal venous ammonemia and glutaminemia were measured. In rats with portal stricture on a high protein diet, the increase in systemic ammonemia did not significantly differ from that found in animals on a standard diet. In contrast, the control group exhibited a higher level (P less than 0.001) of systemic ammonemia after a high protein (102 +/- 7 SEM mumol/l) than after standard diet (36 +/- 1). This hyperammonemia appeared to be of renal origin since there was a significantly higher ammonia difference between renal venous and arterial blood with the high protein than with standard feeding, both in rats with a portal stricture (+ 229 +/- 32 vs. + 24 +/- 8 mumol/l; P less than 0.001). and in control rats (+ 196 +/- 23 vs. + 2 +/- 11; P less than 0.001). This increased renal ammonia release into the circulation induced by the high protein diet was associated with a high renal uptake of circulating glutamine. Moreover, a decreased ammonia passage from the digestive tract into the portal vein and disappearance of intestinal uptake of circulating glutamine was also observed with the high protein feeding.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative pharmacokinetic profiles of cinoxacin and pipemidic acid in humans.

Serum and urinary levels of Cinoxacin and pipemidic acid were determined at 7-day intervals in the same 10 healthy volunteers after a single oral dose of respectively 500 and 400 mg of the drugs. Comparison of results shows that Cinoxacin was absorbed faster (absorption half-life, ta 1/2cin = 0.25 h) than pipemidic acid (ta 1/2pip = 0.37 h) and distributed in a smaller apparent volume (AVDcin = 23.5 1/1.73 m2; AVDpip = 60.1 1/1.73 m2). Biological half-lives were identical (tb 1/2cin = 2.10 h; tb 1/2pip = 2.15 h). On the other hand, serum levels for Cinoxacin at 1, 2 and 4 hours (8.1 +/- 1.5 micrograms/ml, 10.6 +/- 1.5 micrograms/ml, 5.6 +/- 1.3 micrograms/ml respectively) were higher than those for pipemidic acid (3.3 +/- 0.3 micrograms/ml, 3.4 +/- 0.5 micrograms/ml, 2.1 +/- 0.5 micrograms/ml respectively). Urinary excretion of the two derivatives during the 12 hours following their administration was similar (Ucin0-12h = 86%; Upip0-12h = 83%). Mean urinary concentrations were particularly high, still attaining respectively 90 +/- 29 micrograms/ml and 131 +/- 38 micrograms/ml in samples collected between the 9th and the 12th hours; these levels were well above the M.I.C. for the Gram-negative organisms included within the spectrum of activity of these two quinolones. In addition, predictive calculations of serum levels reached after multiple dosing indicate that at an administration rate of 500 mg every 6 or preferably every 4 hours, Cinoxacin concentrations should be sufficiently high to be of interest in the treatment of systemic infections by sensitive organisms.

[Pharmacokinetics of intramuscular mezlocillin in patients with normal and impaired renal function (author's transl)]. / Pharmacocinétique de la mezlocilline administrée par voie intra-musculaire chez des malades à fonction rénale normale et altérée.

Pharmacokinetic values of mezlocillin were determined after a single intramuscular injection of 1 g to 10 subject with normal renal function, 10 patients with stable renal insufficiency and 5 patients with chronic renal failure under long-term haemodialysis. The values obtained in normal subjects were : biological half-life Tb 1/2 0.9 hour; elimination constant Ke 0.790 (h-1); total clearance Ct 449 ml/min/1.73 m2; renal clearance Cr 263 ml/min/1.73 m2. Twelve hours after the injection 72.2 % of the dose administered were recovered in the urine. Theoretical values after repeated injection were calculated from the values obtained in subjects with normal renal function. The loading doses providing steady state serum concentrations were determined for various dosage intervals (2, 3, 4, 6 and 8 hours). In patients with renal insufficiency or treated with haemodialysis, serum levels decreased more slowly. The theoretical Tb 1/2 for zero creatinine clearance was 4.7 hours. Sixty-two percent of the amount of mezlocillin present in the central compartment at the onset of haemodialysis were removed after a 6-hour dialysis session. In all 25 subjects investigated, a significant correlation was found between Ke and Ccr (Ke = 0.1973 + 0.0046 Ccr). This correlation was used to calculate the loading and maintenance doses (and sometimes also the intervals between injections) adjusted to renal function values. Dosage guidelines in relation to the renal function were established from these data.

[Comparative biliary excretion of mezlocillin and 12 other beta-lactam antibiotics (author's transl)]. / Excrétion biliaire comparative de la mezlocilline et de 12 autres bêta-lactamines.

The biliary excretion of mezlocillin was studied on an experimental in vitro model (perfused rabbit liver) and by various methods in man. After addition of 10 mg mezlocillin to blood perfusing isolated rabbit lever preparations (n = 5) during 3 hours, a mean biliary peak of 758 +/- 129 micrograms/ml was recorded between 30 and 60 minutes. The 0-3 h cumulative biliary excretion was 20.3 % of the dose administered. Following a 30 min intravenous infusion of 5 g mezlocillin to 5 healthy subjects, the mean maximal antibiotic activity in the duodenal aspiration fluid was 626.0 +/- 115.0 microgram/ml during the first hour. In 10 cholecystectomized patients with T-tube drainage who received 1 g mezlocillin intramuscularly, a mean biliary peak of 296 +/- 58 micrograms/ml was recorded. The 0-12 h cumulative biliary excretion of the antibiotic was 2.6 % of the dose injected. After intravenous infusion of 5 g mezlocillin, the corresponding values were 505 +/- 118 micrograms/ml and 1.3 % respectively. One hour after rapid intravenous injection of 2 g mezlocillin, the antibiotic activities in samples of serum, common bile duct bile and gallbladder bile collected during cholecystectomy were 28.9 +/- 5.3, 895 +/- 196.1 and 402 +/- 133.2 micrograms/ml respectively. These results were compared with those obtained in similar conditions with 12 other beta-lactam antibiotics.

Pharmacokinetic profile of benoxaprofen in subjects with normal and impaired renal function, prediction of multiple-dose kinetics.

The pharmacokinetic profile of benoxaprofen given as a single oral dose of 600 mg was determined comparatively in 5 healthy volunteers and in 15 patients with various degrees of renal insufficiency (5 of whom were undergoing maintenance hemodialysis). In normal subjects, the half-absorption period (Ka) was 0.63 hours. A mean maximum concentration of 47.3 micrograms/ml could be predicted at 3.6 hours after the dose intake. Serum level decrease was particularly slow. The overall elimination rate constant, Ke, was 0.0234(h-1) and biologic half-life amounted to 28.8 hours. Values for total clearance (Ct=4.8 ml/min/1.73 m2) and renal clearance (Cr=1.6 ml/min/1.73 m2) were low. Of the administered dose of benoxaprofen, 13.9% was recovered in the urine over a 24-hour period. Renal insufficiency did not induce major changes in pharmacokinetic parameters. Under such conditions, it seems advisable to reduce the dose to one-half only in patients with a creatinine clearance of less than 10-20 ml/min/1.73 m2. Predicted serum levels theoretically achieved after repeated administration of a 600-mg dose of benoxaprofen every 6, 12, 24, 36 and 48 hours were calculated. From this evaluation, it appears that therapeutically effective and adequate levels could be obtained after administration of a 600-mg dose every 12 ot 24 hours.

Biliary excretion of cefaclor. Experimental and clinical study.

Biliary excretion of cefaclor, a new orally active cephalosporin, was studied in vitro using an isolated rabbit liver preparation perfused for 3 h (n = 5). Under these conditions, bile recovery amounted to 2.3% of the cefaclor dose added to the circulating blood (10 mg). In humans, after oral administration of a 1-gram dose of cefaclor to cholecystectomized patients provided with a T tube (n = 10), a mean biliary peak concentration of 7.6 +/- 2.4 microgram/ml was observed at the 3rd hour. Cumulative biliary excretion amounted to 0.05% of the administered dose. Assays performed on samples collected during cholecystectomy in 10 patients 1 h after intake of a 1-gram dose of cefaclor showed mean concentrations of 13.7 +- 1.2 micrograms/ml in serum, 8.1 +/- 1.3 micrograms/ml in common duct bile and 5.9 +/- 1.4 micrograms/ml in gallbladder bile. These results were compared with the data obtained after administration of seven other cephalosporins studied under identical conditions.

Pharmacokinetics of mezlocillin in patients with kidney impairment: special reference to hemodialysis and dosage adjustments in relation to renal function.

The pharmacokinetics of Mezlocillin were determined after the intramuscular injection of a single 1-gram dose in 10 subjects with normal renal function, in 10 patients with stabilized renal impairment and in 5 patients with end-stage renal disease submitted to repeated hemodialysis. In normal subjects, biological half-life, Tb1/2, was equal to 0.9 h; total clearance (Ct) to 449 ml/min/1.73 m2; renal clearance (Cr) to 263 ml/min/1.73 m2.72.2% of the administered dose was excreted in the urine within 12 h. In patients with renal insufficiency and in patients undergoing long-term hemodialysis, the serum concentration decrease was markedly slower. During a 6-hour dialysis session, 62% of the Mezlocillin present in the central compartment at the start of hemodialysis was removed. In the 25 subjects under study, a significant correlation was found between the values of Ke and those of creatinine clearance, Ccr (Ke = 0.1973+0.0046 Ccr). This relation was used to calculate the loading doses, the maintenance doses and the dosage intervals adjusted to the degree of renal impairment, allowing assessment of useful dosage recommendations.