1,721,157 research outputs found
Accuracy, necessary conditions for deployment and clinical impact of point-of-care ultrasound in emergency medicine
No full textL’échographie clinique en médecine d’urgence (ECMU) devient une pratique intégrée à l’exercice de la spécialité. En France, son utilisation va se généraliser grâce à la formation de tous les nouveaux internes de médecine d’urgence. La pratique de l’ECMU demande l’existence de preuves scientifiques sur la pertinence diagnostique des techniques utilisées, la disponibilité d’un échographe adapté, la compétence de la pratiquer et l’objectivation de son impact clinique. Après avoir définit l’ECMU, ce texte décrit et analyse l’état d’avancement de ces quatre étapes. Les articles inclus dans ce texte s’intègrent dans chacune d’entre elles. Ils ont pour objectif de participer à trouver les solutions permettant le déploiement et l’évolution de l’ECMU. Enfin, des perspectives d’évolutions de l’ECMU sont proposées.Emergency point-of-care ultrasound (EPOCUS) has become an integrated practice in emergency medicine. In France, systematic EPOCUS teaching for all emergency residents will lead to its widespread use. Integrating EPOCUS practice requires four steps: (1) the publication of accurate scientific data; (2) the availability of suitable ultrasound systems; (3) developing the necessary skills; and (4) highlighting its clinical impact. After defining EPOCUS, this manuscript describes and analyzes the progress of these four steps as the articles herein integrate into each. The aim is to find solutions for the deployment and evolution of EPOCUS. Finally, an outlook for future EPOCUS development is proposed
Impact of septic shock and renal replacement therapy on antimicrobial pharmacokinetics and pharmacodynamics
No full textLe bon usage des antibiotiques en réanimation est un véritable défi. Le sepsis et l’épuration extra-rénale peuvent modifier le comportement des anti-infectieux exposant le patient au risque de sous ou de surdosage. Une meilleure compréhension des altérations liées au sepsis et aux défaillances d’organe permet d’adapter les posologies d’antibiotiques. L’augmentation des posologies d’antibiotiques est nécessaire à la phase initiale du sepsis en raison d’un volume de distribution augmenté. Les adaptations posologiques vont ensuite dépendre des propriétés physico-chimiques de l’anti-infectieux plus que du type d’épuration extra-rénale appliquée. La modélisation pharmacocinétique de population couplée à des simulations de Monte Carlo est une approche pharmaco-statistique élaborée permettant de définir pour une population spécifique les paramètres influençant la PK de l’antibiotique et de prendre en considération la variabilité inter-individuelle. Cette analyse permet également de tester différents schémas posologiques pour un antibiotique donné afin de déterminer la posologie optimale en fonction de différentes fonctions d’organe et selon la susceptibilité des germes traités. La prescription individualisée faisant appel à des logiciels de modélisation PK/PD pourrait permettre à l’avenir d’optimiser l’utilisation des antibiotiques tant en terme d’efficacité que de toxicité tout en limitant l’émergence de résistance.Prescribing antibiotics in an appropriate way is a massive challenge for the intensivists. Sepsis and renal replacement therapy may alter antibiotics pharmacokinetics exposing critically ill patients to under or overdosing. A better understanding of sepsis and organ failure related alterations could help optimizing antibiotic drug dosing. Increased dosing regimens are often necessary at the early phase of sepsis due to increased volume of distribution. Dosing adjustment will then depend on the physicochemical properties of the anti-infective agent rather than renal replacement therapy modalities. A population pharmacokinetic analysis coupled to Monte Carlo simulations consists in a pharmaco-statistic approach aiming to identify covariates influencing antibiotics PK and to consider inter-individual variability. This analysis allows testing different dosing scenarios to determine the optimal dosing regimen according to different levels of organ dysfunction and according to pathogen susceptibility. Individual drug dosing optimisation, using PK/PD modelling software could improve antibiotic efficacy while limiting antibiotic-related toxicity and antimicrobial resistance
The translational approach of the pharmacokinetics of echinocandins : Can the study of the endotoxinic porcine model replace the pharmacokinetic study of patients in septic shock ?
No full textLe sepsis joue un rôle fondamental dans l’altération de la pharmacocinétique (PK) des anti-infectieux, responsable d’un risque de sous ou surdosage chez des patients de réanimation pouvant conduire à un échec thérapeutique. La compréhension de la variabilité PK des anti-infectieux est essentielle afin de proposer une posologie adéquate. De plus, développer un modèle animal de sepsis permettrait d’améliorer la compréhension des altérations PK des anti-infectieux induites par le choc septique.Ce projet de thèse a pour but d’évaluer la capacité du modèle porcin de sepsis à prédire la PK d’anti-infectieux chez l’humain. Pour ce faire, étudier des molécules déjà connues permettrait de confirmer dans un premier temps sa transposition à l’Homme. Les échinocandines, traitement de première intention en cas d’infection fongique, sont au centre de ce projet. Au préalable, des études complémentaires chez des patients de réanimation ont été menées afin d’approfondir nos connaissances sur leur PK dans des situations à risque, comme le recours à des thérapies d’épuration extra-rénale et dans le cadre d’une péritonite secondaire, où la diffusion péritonéale des échinocandines est déterminante pour éradiquer l’infection fongique. Enfin, la PK de la micafungine a été étudiée sur un modèle porcin septique, dont la physiologie est très proche de l’humain, afin de la comparer à celle retrouvée chez les patients septiques. Ces études ont été réalisées à l’aide de modélisation par approche de population.Ces travaux ont mis en exergue la nécessité d’augmenter la posologie des échinocandines chez les patients de réanimation sous peine d’échec thérapeutique. Les thérapies d’épuration extra-rénale, quant à elles, n’altèrent pas la PK des échinocandines. Leur diffusion au sein de la cavité péritonéale, site infectieux fréquent des espèces Candida, est modérée mais serait suffisante afin d’éradiquer l’infection fongique en prenant en compte les CLSI breakpoints. Enfin, la PK de la micafungine chez le modèle porcin septique est similaire à celle retrouvée chez l’humain en considérant une relation allométrique du poids de l’espèce appliquée au volume de distribution central de la micafungine. Ces résultats encourageants tendent à justifier la transposabilité du modèle porcin à l’humain. Si cette hypothèse s’avère exacte, le modèle porcin septique pourrait être utilisé pour l’étude de nouveaux anti-infectieux lors des phases précliniques, afin d’estimer une posologie adéquate chez des patients de réanimation.Sepsis plays a fundamental role in the alteration of the pharmacokinetics (PK) of anti-infection agents, responsible in particular for a risk of under or overdose in intensive care patients which can lead to therapeutic failure. Understanding the PK variability of anti-infectives is essential to provide an adequate initial dosing regimens. Furthermore, the development of an animal model of sepsis would improve our understanding of the PK alterations of anti-infection agents induced by septic shock.The aim of this thesis project is to evaluate the capacity of the porcine model of sepsis to predict the PK of anti-infectives in humans. Thus, the study of already known anti-infection agents would enable to confirm its transposition to humans. Echinocandins, which are the first-line treatment for fungal infections, are at the center of this project. Preliminary studies in intensive care patients were first conducted in order to improve our knowledge of their PK in particular situations, such as the use of renal replacement therapy and in the case of secondary peritonitis, where the peritoneal diffusion of echinocandins is decisive to eradicate fungal infections. Finally, the PK of micafungin was studied in a porcine septic model whose physiology is very close to that of humans, in order to compare it with that found in septic patients. These studies were performed using population-based modeling.This work has highlighted the need to increase the dosing regimens of echinocandins in intensive care patients under threat of therapeutic failure. Renal replacement therapy, on the other hand, do not alter the PK of echinocandins. Diffusion into the peritoneal cavity, a frequent infectious site of Candida species, is moderate for these echinocandins but would be sufficient to eradicate fungal infections given the CLSI breakpoints. Finally, the PK of micafungin is similar between the septic pig model and septic patients considering an allometric relationship of the body weight of these species on the central volume of distribution of micafungin. These encouraging results tend to justify the transposability of the pig model to septic patients. If this hypothesis is correct, the porcine septic model would be used to study new anti-infective agents in the preclinical phases, in order to estimate an adequate initial dosing regimens in intensive care patients
Considerations for the Use of Local Anesthesia in the Frail Elderly: Current Perspectives
No full textThe frail, elderly population is at a high risk of postoperative complications. Besides perioperative rehabilitation techniques and management by geriatric teams, the least invasive techniques in anesthesia are required, making regional anesthesia very interesting in terms of benefit-risk ratio. Among them, local anesthesia is a simple, reproducible, inexpensive technique applied to many superficial or deep surgeries, which should make it a gold standard for the frail person. This review provides an update on the current possibilities for various surgeries and exclusion
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
Variations on the Author
Full text link“Variations on the Author” discusses two of Eduardo Coutinho’s recent films (Um Dia na Vida, from 2010, and Últimas Conversas, posthumously released in 2015) and their contribution to the general question of documentary authorship. The director’s filmography is characterized by a consistent yet self-effacing form of authorial self-inscription: Coutinho often features as an interviewer that rather than express opinions propels discourses; an interviewer that is good at listening. This mode of self-inscription characterizes him as an author who is not expressive but who is nonetheless markedly present on the screen. In Um Dia na Vida, however, Coutinho is completely absent form the image, while Últimas Conversas, on the contrary, includes a confessional prologue that moves the director from the margins to the center of his films. This article examines the ways in which these works stand out in the filmography of a director who offers new insights into the notion of cinematic authorship
Appropriate Similarity Measures for Author Cocitation Analysis
Full text linkWe provide a number of new insights into the methodological discussion about author cocitation analysis. We first argue that the use of the Pearson correlation for measuring the similarity between authors’ cocitation profiles is not very satisfactory. We then discuss what kind of similarity measures may be used as an alternative to the Pearson correlation. We consider three similarity measures in particular. One is the well-known cosine. The other two similarity measures have not been used before in the bibliometric literature. Finally, we show by means of an example that our findings have a high practical relevance.information science;Pearson correlation;cosine;similarity measure;author cocitation analysis
Dispelling the Myths Behind First-author Citation Counts
Full text linkWe conducted a full-scale evaluative citation analysis study of scholars in the XML research field to explore just how different from each other author rankings resulting from different citation counting methods actually are, and to demonstrate the capability of emerging data and tools on the Web in supporting more realistic citation counting methods. Our results contest some common arguments for the continued
use of first-author citation counts in the evaluation of scholars, such as high correlations between author rankings by first-author citation counts and other citation
counting methods, and high costs of using more realistic citation counting methods that are not well-supported by the ISI databases. It is argued that increasingly available digital full text research papers make it possible for citation analysis studies to go beyond what the ISI databases have directly supported and to employ more
sophisticated methods
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