[Emergency management of renal colic]. / Prise en charge des coliques néphrétiques en urgence.

Renal colic (RC) is a common problem in primary care practice. It is estimated that 5-12% of the general population will suffer once RC during his lifetime. The primary care physicians play a central role in the management of urolithiasis. This article summarizes the current recommendations in terms of renal colic emergency management: biological assessment, imaging, pain relief and specific treatment. The vast majority of patients only needs efficient antalgic treatment and an outpatient monitoring. A minimal assessment must however be undertaken to detect complicated RC that will require urgent treatment in urology department. The analysis of the stone after the crisis is crucial to set up a preventive treatment.

[Emergency department overcrowding: a legitimate reason to refuse access to urgent care for non-urgent patients?]. / Engorgement des centres d'urgences: une raison légitime de refuser l'accès aux patients non urgents?

Non-urgent cases represent 30-40% of all ED consults; they contribute to overcrowding of emergency departments (ED), which could be reduced if they were denied emergency care. However, no triage instrument has demonstrated a high enough degree of accuracy to safely rule out serious medical conditions: patients suffering from life-threatening emergencies have been inappropriately denied care. Insurance companies have instituted financial penalties to discourage the use of ED as a source of non-urgent care, but this practice mainly restricts access for the underprivileged. More recent data suggest that in fact most patients consult for appropriate urgent reasons, or have no alternate access to urgent care. The safe reduction of overcrowding requires a reform of the healthcare system based on patients' needs rather than access barriers.

[Access of elderly patients in the emergency department: demographic evolution and ethical perspectives]. / Accès des patients agés aux urgences: evolution démographique et perspectives médico-ethiques.

Due to actual demographic evolution, emergency departments have to face a dramatic increase in admissions of elderly people. The peculiar medical and socio-demographic characteristics of these old patients emphasize the need of specific decision processes and resources allocation. An individual-based approach, related to significant ethical values, should allow better diagnostic and therapeutic attitudes. Such a way to admit, evaluate and treat older patients implies an active collaboration with patients and their relatives, but also with all medical interveners, including in particular primary care physicians.

[Hospitalisation criteria for the acute abdominal pain patient seen at home or in an ambulatory setting]. / L'orientation du patient souffrant d'un syndrome douloureux abdominal aigu a domicile.

Dealing at patient's home with an acute abdominal pain may be particularly challenging for the primary care physician. In such a clinical situation, the part of laboratory and radiological investigations is increasing in the diagnostic process. The decision to keep the patient at home based on a clinical evaluation alone may represent a great medical responsibility for the physician. Emergency departments (ED) are of course in charge of investigating such patients with a wide panel of investigation techniques. But these structures are chronically overcrowded resulting frequently in long and difficult periods of waiting. Based on a literature review, a description of useful clinical symptoms and signs is summarized and should help the decision process for the orientation of the patient.

[Does early analgesia interfere with diagnostic process in acute abdominal pain syndrome?]. / L'analgésie précoce dans le syndrome douloureux abdominal aigu, une entrave à l'établissement du diagnostic?

Early pain management with opioid by patients admitted for abdominal pain is widely contested. Emergency physicians are feared to interfere with physical examination and the ability to make a correct diagnosis. The present review tends to show that opioids are safe in this context. The authors consider that early provision of pain management, even with opioids, should be effective.

[10 years experience in surgical resuscitation at a university hospital center. Determination of a criterion for identifying patients at risk for fatal irreversible coagulopathy]. / Expérience de dix ans de réanimation chirurgicale d'un centre hospitalier universitaire. Détermination d'un critère d'identification des patients à risque de décéder de coagulopathie irréversible.

The authors evaluated ten years of surgical reanimation in the University Centre of Lausanne (CHUV). Irreversible coagulopathy (IC) is the predominant cause of death for the polytraumatized patient. Acidosis, hypothermy, and coagulation troubles are crucial elements of this coagulopathy. The authors looked for a criterion allowing the identification of dying of IC. In a retrospective study, laboratory results of pH, TP, PTT, thrombocyte count and the need for blood transfusion units were checked for each major step of the primary evaluation and treatment of the polytraumatized patients. These results were considered as critical according to criteria of the literature (30). The authors conclude that the apparation of a third critical value may be useful to identify the polytraumatized patient at risk of dying of IC status. This criterion may also guide the trauma team in selecting a damage control surgical approach (DCS). This criterion was then introduced into an algorithm involving the Emergency Department, the operating room and the Intensive Care Unit. This criterion is a new tool to address the patient at the crucial moment to the appropriate hospital structure.

Encapsulation of packaging cell line results in successful retroviral-mediated transfer of a suicide gene in vivo in an experimental model of glioblastoma.

AIMS: Retroviral-mediated gene therapy has been proposed as a primary or adjuvant treatment for advanced cancer, because retroviruses selectively infect dividing cells. Efficacy of retroviral-mediated gene transfer, however, is limited in vivo. Although packaging cell lines can produce viral vectors continuously, such allo- or xenogeneic cells are normally rejected when used in vivo. Encapsulation using microporous membranes can protect the packaging cells from rejection. In this study, we used an encapsulated murine packaging cell line to test the effects of in situ delivery of a retrovirus bearing the herpes simplex virus thymidine kinase suicide gene in a rat model of orthotopic glioblastoma. MATERIALS AND METHODS: To test gene transfer in vitro, encapsulated murine psi2-VIK packaging cells were co-cultured with baby hamster kidney (BHK) cells, and the percentage of transfected BHK cells was determined. For in vivo experiments, orthotopic C6 glioblastomas were established in Wistar rats. Capsules containing psi2-VIK cells were stereotaxically implanted into these tumours and the animals were treated with ganciclovir (GCV). Tumours were harvested 14 days after initiation of GCV therapy for morphometric analysis. RESULTS: Encapsulation of psi2-VIK cells increased transfection rates of BHK target cells significantly in vitro compared to psi2-VIK conditioned medium (3 x 10(6) vs 2.3 x 10(4) cells; P<0.001). In vivo treatment with encapsulated packaging cells resulted in 3% to 5% of C6 tumour cells transduced and 45% of tumour volume replaced by necrosis after GCV (P<0.01 compared to controls). CONCLUSION: In this experimental model of glioblastoma, encapsulation of a xenogeneic packaging cell line increased half-life and transduction efficacy of retrovirus-mediated gene transfer and caused significant tumour necrosis.

Discriminant analysis of transmission of elevated blood pressure in first generation offspring of African green monkeys.

A linear discriminant analysis was applied to blood pressure data of 162 first generation colony-born offspring of normotensive (C), hypertensive (H), or borderline hypertensive (B) African green monkeys who were being selectively bred in an attempt to establish a strain of spontaneously hypertensive monkeys. The offspring were classified according to their parents' blood pressures as CC, HH, or Mixed (e.g. HC). Blood pressures were measured by indirect methods from unanesthetized offspring aged 0.5-6 years of age. The discriminant score was used to classify each of the 533 blood pressure measurements of the CC, Mixed, and HH offspring into one of three predicted groups: normotensive, borderline hypertensive, or hypertensive. The group means of the three predicted groups compared without regard to offspring type were significantly different (p less than .001). In addition, the percentage of blood pressure measurements predicted to be normal or elevated differed among the three offspring groups (p less than .001). 82% of the blood pressure measurements from CC offspring were classified as normotensive, compared with 58% and 40% of the blood pressure measurements from the Mixed and HH groups, respectively. In contrast, 25% of the blood pressure measurements from the HH groups were classified as hypertensive, compared with 10% and 4% from the Mixed and CC groups, respectively. Blood pressures of the normotensive, borderline hypertensive, and hypertensive subgroups derived from the CC group were consistently and significantly lower (p less than .001) than their respective counterparts in the Mixed and HH groups. The results of the discriminant analysis indicate a trimodal distribution of blood pressures in the first generation offspring and a significant separation of blood pressures among the offspring after a single generation.

Development of a nonhuman primate model for spontaneous hypertension. Blood pressures in first-generation offspring.

A breeding colony of two subspecies of African green monkeys has been established in an attempt to develop a strain of nonhuman primates with inherited spontaneous hypertension. Selective breeding of normotensive and hypertensive feral animals has produced over 300 first-generation, colony-born offspring of nine possible types, which were grouped according to parentage. Blood pressures were measured by indirect methods in 335 unanesthetized animals aged 0.5 to 6 years. Analysis of variance and covariance of mean blood pressures of animals aged 0.5 to 6 years indicated significant differences between control and experimental offspring groups (p less than .001) both before and after adjusting for sex, subspecies, age, and body weight. Mean blood pressures of control and experimental (p less than .02) offspring were significantly different from 0.5 to 5 years of age. The slopes of the regression of mean blood pressure on age were significantly different between the control and experimental groups (p less than .001). Multiple linear regression analysis indicated significant differences among blood pressure, body weight, and age (p less than .001) and also between age and weight (p less than .001) between the groups. The relative contributions of age and weight to determining the mean blood pressure differed, however. The results indicate that elevated blood pressures can be detected in offspring with even one parent having elevated blood pressure from as early as 1 year of age and that the tendency to develop elevated blood pressure is transmitted from parent to offspring in this species, thereby providing a strong indication that a hypertensive strain of monkeys can be developed through selective breeding.

Noninvasive measurement of blood pressure in African green monkeys (Cercopithecus aethiops).

Indirect measurements of arterial blood pressure were made in African green monkeys (Cercopithecus aethiops) employing a Doppler ultrasound stethoscope and standard cuff and an Infrasonde automatic blood pressure recorder. Measurements were obtained from anesthetized (10 mg/kg ketamine (HCI) and unanesthetized (1.5 mg/kg ketamine HCI) animals. Ketamine had no significant effect on blood pressure. Indirect measurements from the brachial artery were compared with direct femoral artery measurements and with each other. Systolic blood pressures measured by the Doppler (r = .948) and Infrasonde (r = .920) methods correlated closely with direct measurements but were significantly lower than systolic blood pressures measured by the direct method. Diastolic blood pressures measured by the Infrasonde method agreed closely with direct measurements (r = .947). Systolic blood pressures measured by the indirect methods correlated closely in both anesthetized (r = .973) and unanesthetized (r = .834) animals and were not significantly different. Mean blood pressures calculated from direct and Infrasonde measurements also correlated closely (r = .963), with direct measurements being 4 mmHg higher on the average. Mean blood pressures are less influenced by methodology and are more reproducible than other pressures. These noninvasive methods can be used to obtain simple and accurate measurements of blood pressure from anesthetized and unanesthetized monkeys and are of value in long-term studies in monkeys.