J M Boles

Centre Hospitalier Régional et Universitaire de Besançon, Becoinson, Franche-Comté, France

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Publications (91)249.91 Total impact

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    ABSTRACT: Purpose: To determine the minimum number of supervised transesophageal echocardiography (TEE) that intensivists should per-form to reach competence in performing and interpreting a com-prehensive hemodynamic assessment in ventilated intensive care unit patients. Methods: Prospective and multicentric study. Skills of 41 intensivists (trainees) with no (level 0) or little (level 1) experience in echocardiography was evaluated over a 6-month period, using a previously validated skills assessment score (/40 points). Trainees were evaluated at 1 (M1), 3 (M3) and 6 months (M6) by their tutor while performing 2 TEE examinations in ventilated patients. Competence was a priori defined by a skills assessment score[35/40 points. Results: No difference in the score was observed between level 0 and level 1, except at M1 (22.2 ± 6.2 vs. 25.9 ± 4.4 points, p = 0.03). After 6 months, trainees performed a mean of 31 ± 9 supervised TEE. The score gradually increased from M1 to M6 (24 ± 6, 32 ± 3, and 35 ± 3 points, p \ 0.001), regardless of trainees' initial level. A correlation was found between the number of supervised TEE and the skills assessment score (r 2 = 0.60; p \ 0.001). The number of supervised TEE examinations which best predicted a score [35/40 points was 25, with a sensitivity of 81 % and a specificity of 93 % (area under the ROC curve: 0.91 ± 0.04). A number of 31 supervised TEE examinations predicted a score [35/ 40 points with a specificity close to 100 %. Conclusion: The perfor-mance of at least 31 supervised examinations over 6 months is required to reach competence in TEE driven hemodynamic evaluation of ventilated patient.
    Intensive Care Medicine 01/2013; · 5.54 Impact Factor
  • N. Bizien, A. Renault, J.-M. Boles, A. Delluc
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    ABSTRACT: Introduction The antisynthetase syndrome is characterized by the presence of myositis, interstitial lung disease, arthritis, Raynaud's phenomenon, mechanics hands and anti-Jo1 antibody (histidyl tRNA synthetase). The prognosis of this syndrome is closely related to the severity of lung disease. Myositis can occur several years after lung disease and some patients with interstitial lung disease associated with anti-Jo1 antibodies will not suffer from muscle disease. Case-report We report the case of a 69-year-old man admitted to the medical intensive care unit for acute respiratory insufficiency related to rapidly progressive interstitial lung disease. Antisynthetase syndrome was diagnosed the presence of wrists’ arthritis, ‘mechanic's hands and anti-Jo1 antibodies. Despite the dramatic efficacy of corticosteroid therapy on ventilation parameters, the patient died from a Pseudomonas Aeruginosa nosocomial ventilator-acquired pneumonia. Conclusion Our case emphasizes the importance to search for anti-Jo1 antibodies in the presence of interstitial lung disease. During the course of antisynthetase syndrome, the occurrence of interstitial lung disease is almost always constant and is correlated with poor prognosis.
    Revue De Pneumologie Clinique - REV PNEUMOL CLIN. 12/2011;
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    The Journal of hospital infection 02/2011; 77(2):174-5. · 3.01 Impact Factor
  • Cognition 01/2010; 19(8):706-717. · 3.63 Impact Factor
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    ABSTRACT: Studies about iatrogenic complications do not include patient and/or family information-related problems. We sent a questionnaire by e-mail to 30 doctors working in the medical intensive care units of six university hospitals of the Western part of France; answers were stratified in two groups according to doctors' age and duration of intensive care experience. 55% of doctors inform the patient if possible and the families about the risks of occurrence of such events, but according to the type of procedure involved for 70% of answers; 88% inform the patient if conscious and 91% inform families about a iatrogenic complication once it has occurred, without difference between the two groups. Only 40%, nearly all among the older doctors, state knowing well the recommendations of the French-speaking society of intensive care medicine (SRLF) whereas the younger doctors state knowing them poorly or not at all significantly more than the older doctors. Information about risks is required by the French official medical code of pratice and by the recent 4th of March 2002 law, except in an emergency setting. In case of unconsciousness or impaired mental status, the doctor must inform the family or the patient's surrogate if designated. Information must be given about frequent and serious complications, such as death or severe disability, even if the risk is exceptional. The National Consultative Committee on Ethics (CCNE), the National Health Accreditation Agency (ANAES) and the SRLF have published recommendations underlying the importance of an oral discussion and considering, as justice courts, written information to be only a supplement. Proof that an adequate information was actually delivered is the doctor's responsibility and should be kept it the patient's file. Finally, one should keep in mind a double psychological difficulty in delivering such an information: for the patient and his family due to a difficult emotional context on one hand and for the doctor who may have the impression that his competence is questioned on the other hand.
    Réanimation. 09/2005;
  • J.-M. Boles
    Réanimation 09/2004; 13(s 6–7).
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    ABSTRACT: To evaluate the clinical efficacy of noninvasive continuous positive airway pressure ventilation (CPAP) using a new interface, constituted by a cephalic plastic helmet, in comparison with a standard facial mask. A prospective pilot study with matched-control group, in the emergency department of a teaching hospital. Eleven consecutive adult patients with acute hypoxemic respiratory failure related to cardiogenic pulmonary edema (whether hypercapnic or not) were enrolled in the study, after failure of the initial medical treatment. Each patient treated with CPAP, using the helmet in addition to a standardized medical treatment, was matched with historical control-patient treated with CPAP using a standard facial mask, and selected by gender, age, and PaCO2 levels on admission. Primary end points were improvements of gas exchanges and clinical parameters of respiratory distress. tolerance was evaluated after each CPAP trial. The 22 patients and controls had similar characteristics at baseline. PaCO2 levels, and clinical parameters improved similarly in both groups. No interface intolerance was reported whether using standard facial mask or the helmet. No complications were observed in either group. The helmet allowed CPAP administration for a longer period of time (p=0.045). In-hospital mortality was not different between the two groups. Despite a high dead-space volume (9-15 l), this new helmet interface is an efficient alternative to standard face mask during CPAP, even in cases of severe respiratory acidosis and hypercapnia. It allowed to provide long-duration CPAP, without any adverse events or clinical intolerance.
    Intensive Care Medicine 12/2003; 29(11):2077-80. · 5.54 Impact Factor
  • Intensive Care Medicine 02/2001; 27(1):322. · 5.54 Impact Factor
  • La Presse Médicale 08/2000; 29(23):1285. · 0.87 Impact Factor
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    ABSTRACT: New equipment facilitating the use of spontaneous ventilation with positive expiratory pressure (PEP) has become available in France since January 1996. This technique was applied in 38 patients with severe cardiogenic pulmonary oedema and persistent respiratory distress despite high flow classical oxygen therapy and standard treatment. After 1 hour of ventilation with a flow of 220 l/min of 100% oxygen with an average PEP of 7.7 cm H20, a significant improvement of clinical (heart and respiratory rate) and biological parameters (arterial gases) was observed. There were no side effects. Four patients died during the hospital period and only 1 was intubated. Spontaneous ventilation with PEP is a simple technique for coronary care units and, compared with conventional oxygen therapy, it rapidly improves arterial oxygenation, reduces respiratory work and improves conditions of cardiac load. Acute severe cardiogenic pulmonary oedema seems to be an indication of choice, especially in the elderly, where it may help avoid an often controversial intubation.
    Archives des maladies du coeur et des vaisseaux 11/1998; 91(10):1243-8. · 0.40 Impact Factor
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    ABSTRACT: Non-invasive continuous positive airway pressure (CPAP) seems to decrease the need for intubation in patients with severe cardiogenic pulmonary oedema (CPO) in the intensive care unit. The goals of our study were to delineate indications for CPAP in the emergency department, and to confirm its usefulness in such a setting. We retrospectively assess the evolution of all patients ventilated under CPAP for an acute hypoxaemic respiratory failure over a 1-year period (n = 64 patients). Hypercarbia and respiratory acidosis were present in most patients with CPO (PaCO2 = 54.4+/-22.3 mmHg; pH = 7.27+/-0.13), according to respiratory exhaustion, although initial PaCO2 was low in the pneumonia group. There was a significant improvement of arterial blood gases after 1 hour of ventilation in the CPO group (PaO2 = 254.1+/-121.0 mmHg; PaCO2 = 44.0+/-12.6 mmHg; pH = 7.34+/-0.08; p < 0.0001 for both parameters). In the pneumonia group, oxygenation was also improved but with the persistence of a significant shunt (PaO2 = 157.6+/-84.4 mmHg). Fifty-four patients (84%) were considered as successfully ventilated under CPAP, with no need for intubation and a favourable evolution, mainly in the CPO group. No side effects were reported. In conclusion, CPAP is a useful and easy-to-use ventilatory device in the emergency department. It is now one of our first line treatments during prehospital and emergency care of patients with CPO.
    European Journal of Emergency Medicine 10/1998; 5(3):313-8. · 1.02 Impact Factor
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    ABSTRACT: Intubation and ventilatory assistance are often required in patients presenting severe hypoxemic respiratory distress, but may be contraindicated in elderly subjects due to an underlying condition. The aim of this study was to assess the feasibility, acceptability and contribution of early assistance with spontaneous positive end-expiratory pressure ventilation for elderly subjects admitted to an emergency unit for acute respiratory distress due to cardiogenic pulmonary edema. In our emergency admission unit, all patients with life-threatening hypoxemic respiratory distress are initially assisted with noninvasive spontaneous positive end-expiratory pressure ventilation using a standardized commercial device. We retrospectively analyzed the the files of all patients aged over 70 years who were treated with this standard protocol for cardiogenic pulmonary edema from April 1996 through September 1997. During the study period, 36 patients aged over 70 years required ventilatory assistance according to the standard protocol. Intubation was not reasonable in most of the patients (n = 30). After 1 hour of ventilation, none of the patients developed clinical signs of life-threatening distress. Blood gases demonstrated improved oxygenation (AEPO2 = +184.9 +/- 105.4 mmHg; p < 0.000001). Thirty-two patients were considered to be cured (88.9%) and were discharged; the cardiovascular condition was fatal in 4 patients (11.1%). The rapid improvement in clinical signs and blood gases as well as the final outcome suggests that early assistance with spontaneous positive end-expiratory pressure ventilation is warranted at admission for elderly patients with respiratory distress due to cardiogenic pulmonary edema. Compared with a control group of hospitalized patients cared for during the preceding year and who were not treated with the standard protocol, we also demonstrated a clear improvement in mortality (11% versus 20%).
    La Presse Médicale 06/1998; 27(22):1089-94. · 0.87 Impact Factor
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    ABSTRACT: Elderly patients admitted to the emergency unit are usually hospitalized in medical units. Could a gerontologic evaluation in the emergency room lead to another solution than hospitalization? Since January 1993, a sociomedical geriatric reception has been operating in the emergency unit of the university hospital in Brest, France, every day from 10 AM. to 6 PM. Patients older than 75 years, dependent or at risk of dependence are examined by a geriatrician. The medical situation is evaluated. The nutrition status, the cognitive functions, the thymic functions, the gait, and the functional abilities are systematically studied. In the same time the social evaluation is realised by a social worker. From January 1993 to December 1996, 1,514 patients have been cared for by the social medical team. Once the assessment of each patient was made only 49% of them actually had to be hospitalized in a medical department. The outcome of 100 patients discharged between January 1994 and June 1994 was evaluated one year after their discharge at home, 11 patients were rehospitalized. The reason for rehospitalization were different from the reasons for the first hospitalization. A gerontologic assessment in the emergency room permits to avoid hospitalization in 50% of the cases. One year after discharge at home only 11% of the patients were rehospitalized.
    La Revue de Médecine Interne 03/1998; 19(2):85-90. · 0.90 Impact Factor
  • La Revue de Médecine Interne 02/1998; 19(2):85-90. · 0.90 Impact Factor
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    ABSTRACT: Therapeutic use of helium has been described since 1930. Its main action is to reduce bronchial resistances and consequently overall respiratory work. Helium is substituted for nitrogen. The effects of inhaling a helium-oxygen mixture result exclusively from the physicochemical properties of helium: very low density, high kinetic viscosity. With the advent of selective bronchodilators, use of helium was rapidly abandoned until recently with new interest for the treatment of severe acute asthma. We review the literature on the physical properties of helium-oxygen mixtures and propose an analysis of their therapeutic use in severe acute asthma as well as other indications such as acute episodes of obstructive bronchopneumonia and obstruction of the upper airways. Due to the non-invasive nature of this technique, its easy use with spontaneous ventilation and the large body of theoretical data emphasizing its adaptation for therapeutic use, helium-oxygen gas mixtures offer an important therapeutic option for treating severe diseases with poor prognosis. A multicentric national study is under way to validate its use early by emergency ambulatory units for the treatment of severe acute asthma.
    Revue de Pneumologie Clinique 02/1997; 53(4):177-84. · 0.20 Impact Factor
  • Annales Françaises d Anesthésie et de Réanimation 01/1997; 16(6):780-780. · 0.84 Impact Factor
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    ABSTRACT: Background Elderly patients admitted to the emergency unit are usually hospitalized in medical units. Could a gerontologic evaluation in the emergency room lead to another solution than hospitalization ? Methods Since January 1993, a sociomedical geriatric reception has been operating in the emergency unit of the university hospital in Brest, France, every day from 10 AM. to 6 PM. Patients older than 75 years, dependent or at risk of dependance are examined by a geriatrician. The medical situation is evaluated. The nutrition status, the cognitive functions, the thymic functions, the gait, and the functional abilities are systematically studied. In the same time the social evaluation is realised by a social worker. Results From January 1993 to December 1996, 1,514 patients have been cared for by the social medical team. Once the assessment of each patient was made only 49% of them actually had to be hospitalized in a medical department. The outcome of 100 patients discharged between January 1994 and June 1994 was evaluated one year after their discharge at home, 11 patients were rehospitalized. The reason for rehospitalization were different from the reasons for the first hospitalization. Conclusion A gerontologic assessment in the emergency room permits to avoid hospitalization in 50% of the cases. One year after discharge at home only 11% of the patients were rehospitalized.
    Revue De Medecine Interne - REV MED INTERNE. 01/1996; 17.
  • Annales de medecine interne 02/1995; 146(3):191-2.
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    ABSTRACT: The authors report a case of Trichomonas tenax sinusitis in a 36 years old man with advanced human immunodeficiency virus infection.
    Enzyme and Microbial Technology - ENZYME MICROB TECHNOL. 01/1995; 25(4):610-611.
  • Medecine Et Maladies Infectieuses - MED MAL INFEC. 01/1995; 25(4):610-611.