A prospective, multicenter, randomized trial comparing steroids and pulse cyclophosphamide versus steroids and oral cyclophosphamide in the treatment of generalized Wegener's granulomatosis

OBJECTIVE

To investigate the effectiveness and side effects of oral versus pulse cyclophosphamide (CYC) in combination with corticosteroids (CS) in the treatment of systemic Wegener's granulomatosis (WG).

METHODS

Patients with newly diagnosed systemic WG were enrolled in a prospective, randomized trial. At the time of diagnosis, prior to randomization, every patient received a daily injection of methylprednisolone for 3 days, followed by daily oral prednisone (1 mg/kg/day) and a 0.7-gm/m2 pulse of CYC. Patients were then randomly assigned to receive either prednisone plus intravenous pulse CYC (group A) or prednisone plus oral CYC (group B) as first-line treatment. CYC was given for at least 1 year and was then progressively tapered and discontinued.

RESULTS

Fifty patients were included in the study: 27 in group A and 23 in group B. At 6 months, 24 group A patients (88.9%) were in remission, versus 18 group B patients (78.3%). At the end of the trial, 18 group A patients (66.7%) and 13 group B patients (56.5%) were in remission. In group A, 66.7% of the patients experienced side effects, versus 69.6% in group B. Infectious side effects were significantly more frequent in group B (69.6%) than in group A (40.7%) (P < 0.05). The incidence of Pneumocystis carinii pneumonia was higher in oral CYC-treated patients (30.4%) than in pulse CYC-treated patients (11.1%). Nine group A patients (33.3%) and 10 group B patients (43.5%) died. Actuarial curves showed that relapses were significantly more frequent in group A (59.2%) than in group B (13%) (P = 0.02).

CONCLUSION

Our results indicate that pulse CYC is as effective as oral CYC in achieving initial remission of WG and is associated with fewer side effects and lower mortality. However, in the long term, treatment with pulse CYC does not maintain remission or prevent relapses as well as oral CYC.

Plasma DNA as a marker of cancerous cell death. Investigations in patients suffering from lung cancer and in nude mice bearing human tumours

Plasma DNA that circulates mainly as mononucleosomes is a cell death marker. Its significance and prognostic value in cancer as compared to other tumour markers was investigated in 68 patients hospitalised for lung cancers. Prognostic values of the various studied parameters were evaluated using the Cox's model. The cellular origin of plasma DNA was further investigated in nude mice transplanted with human lung adenocarcinoma. Plasma DNA concentrations were increased in cancer patients as compared to normal subjects (P < 0.01). They were higher in patients with extended (Stage 4) disease than in patients with limited stage disease (P < 0.05). Plasma DNA concentrations, serum lactate dehydrogenase activities and neuron-specific enolase concentrations were correlated all together in small cell lung carcinoma (SCLC) and in non-SCLC. Similar relationships were found between survival and each of these three cell death/tumour markers (P < 0.02-0.005). Plasma DNA from mice bearing human tumour hybridised with both mouse and human plasma DNA, while plasma DNA from endotoxin-injected mice hybridised only with mouse plasma DNA. In conclusion, in patients suffering from lung cancer, plasma DNA as well as LDH and NSE represent cell death markers that are correlated with survival. At a time when apoptosis pathways appear to be potential targets for cancer therapy, plasma DNA is a cell death/tumour marker that should be taken into account in studying the cancerous process in human diseases.

Primary pulmonary lymphomas. A clinical study of 70 cases in nonimmunocompromised patients

We studied 70 patients with biopsy-proven pulmonary non-Hodgkin's lymphomas without extrathoracic involvement or mediastinal adenopathy to determine the clinical, imaging, and endoscopic features of this condition in a homogeneous series. In low-grade (LG) lymphomas, symptoms were cough, dyspnea, chest pain, hemoptysis. Imaging features consisted of localized alveolar opacities, infiltrative diffuse opacities, atelectasis, and pleural effusions. Inflammatory changes of the mucosa were present in some patients, leading to bronchial stenosis in 7; biopsies showed lymphomatous infiltration in 12. Prognosis of LG lymphomas was excellent, with 93.6 percent survival at five years. High-grade lymphomas differed from LG lymphomas principally by a more aggressive course and a worse survival. Inflammatory changes occurred in seven of nine cases leading to stenosis in two, and biopsies showed lymphomatous involvement in five. The profile of primary pulmonary lymphomas in this study could help clinicians consider this condition and prompt them to evaluate new diagnostic tools.

Microscopic polyangiitis with alveolar hemorrhage. A study of 29 cases and review of the literature. Groupe d'Etudes et de Recherche sur les Maladies "Orphelines" Pulmonaires (GERM"O"P)

Microscopic polyangiitis (MPA) is a systemic small-vessel vasculitis primarily associated with necrotizing glomerulonephritis and pulmonary capillaritis. In this retrospective study of 29 patients with MPA and alveolar hemorrhage (AH), we characterized the pulmonary manifestations at presentation and assessed the short- and long-term outcome. AH was diagnosed when bronchoalveolar lavage was macroscopically bloody, or contained hemosiderin-laden macrophages, in the absence of lung infection or pulmonary edema. MPA was diagnosed when AH was associated with focal segmental necrotizing glomerulonephritis at kidney biopsy or pathologically proved small-vessel vasculitis. There were 17 women and 12 men, with a mean age of 55.8 +/- 16.7 years. The onset was rapidly progressive, but in 8 (28%) patients, symptoms preceded the diagnosis for more than 1 year. The most constant systemic findings associated with AH were glomerulonephritis in 28 (97%) patients; fever (62%); myalgia and arthralgia (52%); weight loss (45%); ear, nose, and throat symptoms (31%); and skin involvement (17%). Lung opacities were bilateral in 26 (90%) patients, most frequently involving the lower part of the lungs. Bronchoalveolar lavage, performed in 27 patients, was hemorrhagic in 25 (93%), and contained numerous siderophages in others. Most patients were severely anemic (mean hemoglobin, 8.1 +/- 1.8 g/dL). ANCA, present in 27 (93%) patients, gave a perinuclear (14), cytoplasmic (11), or mixed (1) pattern. Mean serum creatinine level was 407 +/- 415 mumol/L. Renal biopsy confirmed the presence of necrotizing glomerulonephritis in 27 patients. Patients were treated with corticosteroids (100%), cyclophosphamide (79%), plasmapheresis (24%), dialysis (28%), and mechanical ventilation (10%). The overall mortality rate was 31% (9 patients). Deaths were related to vasculitis (5 patients) or side effects of treatment (4). Deaths were more frequent in aged or mechanically ventilated patients. The 5-year survival rate was 68%. The recovery of respiratory function among survivors was clinically considered complete in 20 (69%) patients. However, 7 patients (24%) had persistent alterations on pulmonary function tests. Of the 11 patients who had relapses, 2 died from AH.

Idiopathic chronic eosinophilic pneumonia. A clinical and follow-up study of 62 cases. The Groupe d'Etudes et de Recherche sur les Maladies "Orphelines" Pulmonaires (GERM"O"P)

Idiopathic chronic eosinophilic pneumonia (CEP) is a rare disorder of unknown cause with nonspecific respiratory and systemic symptoms but rather characteristic peripheral alveolar infiltrates on imaging, developing mainly in women and in atopic subjects. The disorder is highly responsive to oral corticosteroid therapy, but relapses are frequent on reducing or stopping treatment. The long-term course of the disease and data regarding outcome, particularly the need for prolonged oral corticosteroid therapy and the development of severe asthma, are somewhat contradictory. A multicentric retrospective study was conducted in an attempt to describe better the initial features and, above all, the later course of CEP in a large homogeneous series of 62 stringently selected patients of whom 46 were followed for more than 1 year. The prevalence of smokers was low (6.5%) and about half of our patients (51.6%) had a previous, and often prolonged, history of asthma. The clinical and roentgenographic features were in keeping with previous studies, but we found that computed tomography could disclose ground glass opacities not detected by X-ray, and that migratory infiltrates before treatment were more frequent (25.5%) than reported previously. The bronchoalveolar lavage cellular count always showed a striking eosinophilic pattern, thus allowing distinction between CEP and cryptogenic organizing pneumonia, both syndromes sharing many common clinical and imaging features. About two-thirds of the patients (68%) showed a ventilatory defect in pulmonary function tests, with about one-half of these presenting with an obstructive pattern, sometimes without previous asthma. Along with the submucosal eosinophilic infiltration noted in 2 patients without ventilatory defect, this is strong evidence to confirm that CEP is not only an alveolointerstitial but also an airway disease. The dramatic response to oral corticosteroid therapy was observed in all treated patients. Although only 1 patient initially treated for less than 6 months did not relapse, longer oral corticosteroid therapy in no way provided protection from further relapses. We thus propose to try to wean oral corticosteroid therapy after 6 months in patients without severe asthma, because recurrences remain responsive to oral steroids. However, prolonged oral corticosteroid therapy was necessary in the majority of patients, with 68.9% of those followed for more than 1 year still on oral corticosteroid therapy at the last follow-up, either because of relapse or because of severe asthma.

Self-expandable prostheses in the tracheobronchial tree

Under endoscopic and radiologic control, two types of self-expandable metal prostheses were implanted in tracheobronchial lesions to help reestablish airway caliber. Thirty-nine metal stent prostheses (6-20 mm in diameter) and 35 Gianturco stents (30 mm in diameter) were used in 55 adult patients with 62 lesions of the trachea (n = 33) or bronchi (n = 29). All lesions except one were endoscopically confirmed to be noninflammatory. Immediately after implantation, radiologic and endoscopic studies verified reestablishment of a satisfactory airway diameter in all patients. At a mean follow-up of 10.35 (range, 3-27) months, improvement in the respiratory status of 49 of the 55 patients (89%) was maintained and tolerance of the device was excellent. For the Wallstent endoprosthesis, the six complications observed at endoscopy were successfully treated. The Gianturco stent, however, led to a high rate of complications: 30% of cases had migration and/or rupture of the metallic mesh, potentially leading to obstruction or wall perforation; one case of respiratory distress was fatal. This procedure offers rapid epithelialization and incorporation of the device into the tracheobronchial wall.

Idiopathic chronic eosinophilic pneumonia and asthma: how do they influence each other?

Since idiopathic chronic eosinophilic pneumonia (ICEP) and asthma are frequently associated, their possible reciprocal influence on clinical presentation and evolution were investigated. The clinical and follow-up features of 53 cases of ICEP, of which 41 (77%) had asthma, were reviewed retrospectively. Asthma preceded the diagnosis of ICEP in 26 patients, was contemporaneous in eight patients, and developed 17 +/- 12 months after ICEP in seven patients. Presentation of ICEP was similar in asthmatics and nonasthmatics with the exception of a higher level of total immunoglobulin E in the former group. Patients with asthma at the time of diagnosis of ICEP were more likely to remain free of relapse of ICEP (56 versus 23%) and had a lower number of relapses per year of follow-up (median 0 versus 0.24). Moreover, they were treated more frequently with long-term inhaled corticosteroids (88 versus 31%) at last follow-up. Asthma got worse after the diagnosis of ICEP and frequently required long-term oral corticosteroids. To conclude, among patients with idiopathic chronic eosinophilic pneumonia, asthmatics have a lower frequency of relapse than nonasthmatics, possibly because of a higher use of inhaled corticosteroids. The occurrence of idiopathic chronic eosinophilic pneumonia in asthmatics is often associated with the development of severe asthma.

Descriptive analysis of emergency hospital admissions of patients with Alzheimer disease

The aim of this project was to study the underlying reasons for emergency hospital admission of patients with dementia of the Alzheimer type (DAT) and their characteristics. This prospective 4-month study identified 118 patients with DAT, most of whom were referred to the two emergency departments of the Toulouse University Hospital. The two main reasons for admission were behavioral problems (26.3%) and falls (18.6%). Patients were generally at an advanced stage of the disease process and had substantial evidence of poor nutritional status and loss of activities of daily living ability. About one third of patients had already been admitted to the hospital for the same reasons in the preceding months. Psychotropic drugs predominated (71%) among the current medications taken by the patients and were mainly anxiolytics and neuroleptics. Finally, the discharge report indicated that medications were a contributing factor in the disorders of 25% of patients. We believe that improved information for caregivers and early management and treatment are essential to respond adequately to the problems raised by this population.

Bronchoalveolar lavage in liquid paraffin pneumonitis

We evaluated cells and lipids recovered in the bronchoalveolar lavage fluid from seven patients with liquid paraffin pneumonitis. For each patient, the BALF was whitish with oil droplets on the surface. Alveolar macrophages contained numerous, large vacuoles that did not react with May-Grunwald-Giemsa, Papanicolaou, or periodic acid-Schiff but were stained in black with Sudan B, orange with Sudan III and red with oil Red O. Liquid paraffin was identified on thin layer chromatography of BALF-extracted lipids as a very hydrophobic compound migrating on the solvent front as control liquid paraffin. This abnormal spot was definitely identified as liquid paraffin by infrared spectroscopy and gas liquid chromatography for the first patient. The number and percentage of AMs were largely decreased in the BALF of each patient, whereas the number of neutrophils, eosinophils and lymphocytes was increased. These findings suggest that this cell-mediated inflammatory response plays a role in the development of interstitial fibrosis at late stages of liquid paraffin pneumonitis.

Multiple perforating and non perforating pilomatricomas in a patient with Churg-Strauss syndrome and Rubinstein-Taybi syndrome

We report an unusual association of multiple perforating and non-perforating pilomatricomas with Churg-Strauss syndrome, and a dysmorphic syndrome evocative of Rubinstein-Taybi syndrome. These syndromes may be independent, but these rare diseases and genetic abnormalities may be linked together.

Peritraumatic dissociation, acute stress, and early posttraumatic stress disorder in victims of general crime

OBJECTIVE

To compare the relation between peritraumatic dissociation and acute stress and the early development of posttraumatic stress disorder (PTSD) in victims of general crime.

METHOD

A total of 48 subjects were assessed within 24 hours of the trauma, using the Peritraumatic Dissociative Experiences Questionnaire Self-Report Version (PDEQ-SRV). They were followed longitudinally to assess acute stress (2 weeks after the assault,) using the Standford Acute Stress Reaction Questionnaire (SASRQ), and posttraumatic stress (at 5 weeks), using the Clinician-Administered PTSD Scale (CAPS) and the Impact of Event Scale (IES).

RESULTS

Among PTSD subjects mean PDEQ scores were significantly higher (mean 3, SD 0.9) than in those without PTSD (mean 2.3, SD 0.7) (t = 2.78, df 46, P = 0.007). Among PTSD subjects, mean SASRQ scores were significantly higher (mean 97.9, SD 29.2) than in those without PTSD (mean 54.8, SD 28.2) (t = 4.9, df 46, P = 0.00007).

CONCLUSIONS

High levels of peritraumatic dissociation and acute stress following violent assault are risk factors for early PTSD. Identifying acute reexperiencing can help the clinician identify subjects at highest risk.

Symptoms and serum precipitins in workers exposed to dry sausage mould: consequences of exposure to sausage mould

OBJECTIVE

Hypersensitivity pneumonitis due to dry sausage mould has been reported in workers who brush off the excess mould which coats dry sausage. Prevalence of symptoms and sensitization to mould among these pork-butchery workers is unknown. The aim of the study was to assess the clinical, radiographic, functional, and immunological features in exposed and non-exposed workers in semi-industrial pork butcheries.

PATIENTS AND METHODS

Symptoms, and serum precipitins against mould extracts, were studied in workers in semi-industrial pork butcheries. Of 600 workers asked to participate, 123 (20.5%) were included. Fifty-nine workers, exposed to dry (raw) sausage mould and Penicillium nalgiovense were compared with 64 non-exposed subjects, for symptoms, chest X-rays, spirometry and CO-transfer measurements. Precipitating antibodies were detected by immunoelectrophoresis and electrosyneresis.

RESULTS

Sneezing, cough, dyspnoea, nasal obstruction, headache, and discomfort were significantly more frequent in the exposed group at work and after work than in the control group (P < 0.05). The prevalence of precipitating antibodies for sausage mould was higher in the exposed group (37%) than in the non-exposed group (9%) (P < 0.01). The mean number of precipitating lines measured by electrosyneresis was higher in exposed workers than in non-exposed workers for mould extract (1.09 vs 0.28, P < 0.05) and for Penicillium nalgiovense (1.77 vs 0.33, P < 0.05). No specific X-ray opacity or lung function impairment was found in either group.

CONCLUSIONS

Clinical symptoms and sensitization to Penicillium nalgiovense are frequent among workers exposed to mould during brushing in dry sausage plants.

Les splénomégalies sarcoïdosiques : caractéristiques cliniques et évolutives. À propos de 17 observations

PURPOSE

To describe the clinical features, biological datas and outcome of patients with systemic sarcoidosis and splenomegaly.

METHODS

A retrospective analysis of 17 patients presenting splenomegaly and sarcoidosis with histological proof.

RESULTS

Splenomegaly was clinically perceptible in 13 patients, with a spleen size that extended 4 cm or more below the costal margin in 11 patients. It was painful in five cases. The more frequent clinical features are constitutional symptom (fever in 9 cases) and hepatomegaly (N =7). Chest X-ray showed bilateral hilar lymphadenopathy in nine patients and no abnormality in five cases. Serum angiotensin converting enzyme levels were elevated in 81% of cases. Thrombopenia (N =5) and hypersplenism (N =5) were also observed. Corticosteroid were given to 88% with a good clinical and biological response including a decrease in the spleen volume. Corticotherapy and splenectomy (performed in two patients to rule out lymphoma) didn't change outcome of disease. Sarcoidosis is often chronical (82%) and extensive.

CONCLUSION

Splenomegaly may be present in sarcoidosis. Management is not standardized. Corticosteroid is indicated for symptomatic or massive splenomegaly. Splenomegaly is frequently in chronic and extensive sarcoidosis.

High-resolution computed tomography abnormalities in ex-insulators annually exposed to asbestos dust

BACKGROUND

characterize To the effects of high asbestos exposure during annual periods of insulation.

METHOD

170 ex-workers underwent clinical examination, spirometry, standard chest X-rays and high-resolution computed tomography (HRCT). Asbestos exposure was retrospectively assessed for latency, duration, and intensity.

RESULTS

Sixty-six percent of these workers were annually exposed to high concentrations of asbestos dust. Respiratory symptoms were mild. One hundred and nineteen subjects had pleural or pulmonary changes on HRCT, compatible with asbestos exposure. Localized pleural thickening was found in 113 subjects (66.5%); pulmonary nodules or lines in 35 (20.6%). The presence of pleural plaques was linked to intensity of asbestos exposure (P <.01), and length of employment (P <.05). Parenchymal lesions were related to intensity (P <.05) and duration of exposure (P <.05). Lung function of subjects with X-ray changes was not significantly altered.

CONCLUSIONS

Annual asbestos exposure led to a high prevalence of pleural plaques and to mild parenchymal anomalies.

[Pneumorenal syndrome induced by d-penicillamine: Goodpasture's syndrome or microscopic polyarteritis?]

Diffuse alveolar haemorrhage associated with glomerulonephritis is a rare but serious complication of d-penicillamine therapy. A case is reported which illustrates the usefulness of bronchoalveolar lavage and kidney needle biopsy for the early diagnosis of this condition. A search for antiglomerular basement membrane antibodies in serum was negative, whereas antigranulocyte cytoplasmic antibodies were present. These immunological results differentiated the disease from Goodpasture's syndrome to which it is clinically related and placed it in the same category as microscopic polyarteritis. After treatment with corticosteroids, cytostatic drugs and plasmapheresis, the outcome was favourable in contrast with the usually poor prognosis.

Signal transducing mechanisms in human platelets stimulated by cotton bract tannin

Cotton bract tannin is a potent stimulus for platelet aggregation and secretion. Tannin has been shown to stimulate the phosphorylation of two 19-kD and 47-kD cytosolic proteins in platelets, but earlier steps in signal transducing mechanisms of platelet activation are unknown. In this study, measurements of 32P-labeled phospholipids, 14C-labeled arachidonic acid, and levels of intracellular free calcium (Ca2+) were performed before and after the addition of thrombin (1 U/ml) or various concentrations of tannin to human platelets. The results showed that tannin induced a dose-dependent synthesis of phosphatidic acid, an early and transient hydrolysis of phosphatidylinositol monophosphate and bisphosphate, a transient synthesis of diacylglycerol, and a release of arachidonic acid metabolites. The kinetics of phosphatidic acid, diacylglycerol, and arachidonic acid metabolite synthesis were similar after platelet stimulation by tannin (75 micrograms/ml) or thrombin. Tannin also induced a reversible rise of intracellular Ca2+ due to a mobilization of the internal stores and an influx of extracellular Ca2+. These results suggest that cotton bract tannin, as thrombin, activates human platelets by phospholipase C and A2 activations, release of diacylglycerol, and mobilization of intracellular free Ca2+.

Cotton condensed tannin: a potent modulator of alveolar macrophage host-defense function

Alveolar macrophages are the resident airway cells primarily responsible for the protection of the lungs against inhaled toxins and other biologically active material. A number of functional capabilities constitute their host-defense function. They can phagocytize and inactivate foreign material by production of reactive oxygen intermediates or the action of hydrolytic enzymes. In the absence of phagocytosis, macrophages can secrete reactive oxygen intermediates or enzymes that inactivate extracellular biologically active material. They also can secrete metabolites of arachidonic acid and other cytokines that contribute to the inflammatory response of the lungs. Macrophages also secrete a variety of peptide and lipid chemotactic factors that lead to the recruitment of other inflammatory cells into the airways. The condensed tannins, which constitute a significant percentage of the water soluble compounds present in respirable cotton mill dust, dramatically alter the host-defense function of alveolar macrophages in vitro. Tannin inhibits both phagocytosis and production of reactive oxidants in a dose-dependent manner with EC50's of 16 micrograms/mL and 3 micrograms/mL, respectively. This inhibition dramatically decreases the ability of resident alveolar macrophages to clear and detoxify potentially harmful inhaled particles. However, at similar concentrations, tannin stimulates the dose-dependent secretion (EC50 = 15 micrograms/mL) of a low molecular weight lipid neutrophil chemotactic factor that could result in an inflammatory reaction with the recruitment of neutrophils into the lungs. At slightly higher concentrations, tannin promotes the dose-dependent release of arachidonic acid from the macrophage membranes (EC50 = 65 micrograms/mL), which could also contribute to the local inflammatory reaction. Finally, tannin also causes secretion of the cytokine, interleukin-1, from the monocyte precursors of macrophages with an EC50 of 32 micrograms/mL. Interleukin-1 has been implicated as one of the causative agents in the development of fever.

Distinct signal transduction pathways for activation of rabbit alveolar macrophages in vitro by cotton bract tannin

These experiments were designed to study signal transduction pathways in alveolar macrophages stimulated by condensed tannin or zymosan. Condensed tannins, present in cotton mill dust, alter the host-defense function of alveolar macrophages and may contribute to the pathogenesis of byssinosis. We tried to determine the early steps in signal transduction mechanisms of cell activation by tannin. With the quantification of 51Cr release, we determined that tannin was cytotoxic for the cells after 30 min activation with 130 micrograms for 2 x 10(6) cells. 51Cr release was similar for control cells and zymosan- or 30 micrograms tannin-activated cells. Using the luciferine luciferase reaction, we showed that tannin markedly depleted ATP cell content. In inositol-labeled cells, tannin increased inositolphosphate release in a dose-dependent manner. In lysoPAF-labeled cells, tannin induced synthesis of phosphatidic acid and diglycerides. In the presence of ethanol, the level of tannin-induced phosphatidic acid was slightly reduced, and phosphatidylethanol was synthesized. No phosphatidylethanol was found in alveolar macrophages stimulated by zymosan in the presence of ethanol. GF 109203X, a specific inhibitor of protein kinase C decreased only tannin-induced phosphatidylethanol synthesis. In conclusion, tannin (at 30 or 130 micrograms/ml) activated an inositol phospholipase C in alveolar membranes. Phosphatidylcholine phospholipases C and D were found only at the higher concentration of tannin.

Conception d’un programme d’enseignement par simulation dans le DES de médecine d’urgence selon la méthode du modèle logique

Dans le cadre de la création du diplôme d’études spécialisées de médecine d’urgence (DESMU), l’intégration d’un programme national de simulation est difficile à promouvoir face à la grande variabilité des ressources de chaque université. Nous proposons une méthodologie de conception et de mise en oeuvre d’un programme de formation par simulation (PFS) fondée sur les spécificités de chaque université et intégrant une démarche évaluative selon une approche par compétences. La méthode du modèle logique a été utilisée pour définir les objectifs en lien avec le contexte de formation, préciser les ressources disponibles puis décrire le processus de mise en oeuvre et d’évaluation d’un PFS intégré au DESMU de l’université de Toulouse. La méthode du modèle logique a permis la conception d’un PFS à partir de six étapes successives : 1) l’objectif qui tient compte du contexte ; 2) les ressources ; 3) les activités ; 4) les groupes visés par le programme ; 5) les produits issus des activités ; 6) les résultats à court, moyen et long termes. Il a permis d’intégrer la simulation dans le cursus de formation des DESMU selon une approche réaliste et adaptée aux ressources locales avec un processus d’évaluation cohérent (satisfaction, mobilisation des compétences en situation de soins et impact sur l’organisation des soins). Dans le cadre d’une approche par compétences dans le cursus des DESMU, le modèle logique a mené à la conception, à la mise en oeuvre et à l’évaluation d’un PFS cohérent avec comme défi de rester dynamique afin d’intégrer l’évolution des variables pendant la période du projet.