Place de l’assistance circulatoire dans le choc cardiogénique en France en 2018 : revue de la littérature et perspectives

Le choc cardiogénique reste de nos jours une entité mal définie, assez fréquente en pratique clinique (60 000–70 000 cas/an en Europe), dont le pronostic est sombre, avec une mortalité souvent supérieure à 40 % à 30 jours. À travers cette revue de la littérature, nous essaierons de définir cette entité et ses étiologies, avant de parler de son incidence et de son pronostic. L’approche physiopathologique du choc cardiogénique nous permettra par la suite d’approcher sa prise en charge thérapeutique classique (gestion de la volémie, amines inotropes et vasoconstrictives, ventilation) et les limites de cette dernière. Ainsi, nous aborderons les assistances circulatoires et cardiocirculatoires disponibles en France, afin de les envisager au sein d’une stratégie globale de prise en charge du patient en choc cardiogénique. Nous discuterons plus spécifiquement leurs indications ainsi que l’importance du moment d’implantation afin d’optimiser leur efficacité. Enfin, nous évoquerons les assistances actuellement en développement, mais également les nouvelles stratégies thérapeutiques qui pourraient arriver dans les prochaines années.

Faire face à la menace infectieuse en réanimation : de la veille épidémiologique à l’innovation. Actes du séminaire de recherche translationnelle de la Société de réanimation de langue française (5 décembre 2017)

Le séminaire annuel de la Commission de recherche translationnelle de la SRLF a pour but de réunir des cliniciens et scientifiques autour de grandes thématiques de recherche en médecine intensive et réanimation. La quatrième édition du séminaire a porté sur l’infectiologie, thématique au centre des préoccupations des réanimateurs. Les interventions se sont ainsi focalisées sur des aspects aussi divers que les relations hôtes–pathogènes, la contribution de pathogènes dans des pathologies habituellement considérées comme non infectieuses, l’émergence de nouveaux risques infectieux, les avancées technologiques du diagnostic moléculaire des infections et le développement de stratégies antibactériennes alternatives à l’antibiothérapie classique.

Influence of Age on Decision-Making Process to Limit or Withdraw Life-Sustaining Treatment in the Intensive Care Unit - A Single Center Prospective Observational Study

BACKGROUND

The increasing age in the industrialized countries places significant demands on intensive care unit (ICU) resources and this triggers debates about end-of-life care for the elderly.

OBJECTIVES

We sought to determine the impact of age on the decision-making process to limit or withdraw life-sustaining treatment (DWLST) in an ICU in France. We hypothesized that there are differences in the decision-making process for young and old patients.

DESIGN, SETTING, PARTICIPANTS

We prospectively studied end-of-life decision-making for all consecutive admissions (n=390) to a tertiary care university ICU in Toulouse, France over a period of 11 months between January and October 2011.

RESULTS

Among the 390 patients included in the study (age ≥70yo, n=95; age <70yo, n=295) DWLST were more common for patients 70 years or older (43% for age ≥70yo vs. 16% for age <70yo, p <0.0001). Reasons for DWLST were different in the 2 groups, with the 'no alternative treatment options' and 'severity of illness' as the most frequent reasons cited for the younger group whereas it was 'severity of illness' for the older group. 'Advanced age' led to DWLSTs in 43% of the decisions in the group ≥70yo (vs. 0% in the group <70yo, p <0.0001). Multivariate logistic regression showed a high SAPS II score and age ≥70yo as independent risk factors for DWLSTs in the ICU. We did not find age ≥70yo as an independent risk factor for mortality in ICU.

CONCLUSION

We found that age ≥70yo was an independent risk factor for DWLSTs for patients in the ICU, but not for their mortality. Reasons leading to DWLSTs are different according to the age of patients.

Monitorage hémodynamique dans le SDRA : que savoir en 2018

Environ deux tiers des patients atteints de syndrome de détresse respiratoire aiguë (SDRA) présenteront une instabilité hémodynamique avec recours aux vasopresseurs. Sous ventilation mécanique, la diminution de précharge du ventricule droit (VD) suite à l’augmentation de la pression pleurale et l’augmentation de la postcharge du VD secondaire à l’élévation de la pression transpulmonaire seront des phénomènes exacerbés en cas de SDRA. Les risques encourus sont une diminution du débit cardiaque global et l’évolution vers un cœur pulmonaire aigu (CPA). Le contrôle de la pression motrice, de la pression expiratoire positive et la lutte contre l’hypoxémie et l’hypercapnie auront un impact autant respiratoire qu’hémodynamique. L’échographie cardiaque tient un rôle central au sein du monitorage hémodynamique au cours du SDRA, à travers l’évaluation du débit cardiaque, des différentes pressions de remplissage intracardiaques et le diagnostic de CPA. Le cathéter artériel pulmonaire est un outil de monitorage complet, indiqué en cas de défaillance cardiaque droite ou hypertension artérielle pulmonaire sévère ; mais le risque d’effets indésirables est élevé. Les moniteurs utilisant la thermodilution transpulmonaire permettent un monitorage du débit cardiaque en temps réel et sont d’une aide précieuse dans l’évaluation du statut volumique. L’évaluation de la précharge dépendance ne doit pas s’effectuer sur les variabilités respiratoires de la pression pulsée ou du diamètre des veines caves, mais à travers l’épreuve de lever de jambe passif, le test d’occlusion télé-expiratoire ou encore les épreuves de remplissage titrées.

Feasibility of a text-based smoking cessation intervention in rural older adults

Text-based interventions are effective for smoking cessation, but have not been tested in rural older adults. The purpose of this study was to compare the feasibility, acceptability and preliminary efficacy of a text-based Scheduled Gradual Reduction (SGR) program to a non-SGR text messaging support condition among rural older adults. Adults over 60 years were randomized to either: (i) the SGR program (n = 20), a text-based program to reduce smoking over 4-weeks plus text-based support messages; or (ii) control (n = 20), receipt of text-based support messages only. Participants completed surveys at baseline and end of program to assess feasibility and acceptability of the intervention, and biochemically validated 7-day point prevalence cessation was assessed at end of treatment. Most participants (81%) reported reading all the messages they received. Participants found both interventions useful in quitting smoking (SGR = 57%, Control = 63%) and would recommend it to a friend (SGR = 72%, Control = 79%). Although not statically significant, the SGR group had a higher rate of biochemically validated cessation (SGR = 15%, Control = 5%, Cohen d = 0.67). Among those still smoking, the median percent reduction in cigarettes was 33.3% for both groups. Text-based cessation interventions are feasible, acceptable and can be easily disseminated to rural older adult tobacco users.

3-month prognostic impact of severe acute renal failure under veno-venous ECMO support: Importance of time of onset

PURPOSE

Veno-venous ECMO is increasingly used for the management of refractory ARDS. In this context, acute kidney injury (AKI) is a major and frequent complication, often associated with poor outcome. We aimed to identify characteristics associated with severe renal failure (Kidney Disease Improving Global Outcome (KDIGO) 3) and its impact on 3-month outcome.

METHODS

Between May 2009 and April 2016, 60 adult patients requiring VV-ECMO in our University Hospital were prospectively included.

RESULTS

AKI occurrence was frequent (75%; n=45), 51% of patients (n=31) developed KDIGO 3 - predominantly prior to ECMO insertion - and renal replacement therapy was required in 43% (n=26) of cases. KDIGO 3 was associated with a lower mechanical ventilation weaning rate (24% vs 68% for patients with no AKI or other stages of AKI; p<0.001) and a higher 90-day mortality rate (72% vs 32%, p=0.002). Multivariate logistic regression suggested that KDIGO 3 occurrence prior to ECMO insertion, as well as PaCO2>57mmHg and mSOFA>12 were independent risks factors for 90-day mortality.

CONCLUSION

KDIGO 3 AKI occurrence is correlated with the severity of patients' clinical condition prior to ECMO insertion and is negatively associated with 90-day survival.

Tissue iron quantification in chronic liver diseases using MRI shows a relationship between iron accumulation in liver, spleen, and bone marrow

AIM

To investigate iron loading within the liver, pancreas, spleen, and bone marrow using magnetic resonance imaging (MRI) transverse relaxation rate (R2*), in patients with diffuse liver diseases; to evaluate the relationships between iron accumulation in these tissue compartments; and to assess the association between tissue iron overload and the pattern of hepatic cellular iron distribution (hepatocytes versus Kupffer cells).

MATERIAL AND METHODS

Fifty-six patients with diffuse liver diseases had MRI-derived R2* values, using a multi-echo chemical-shift encoded MRI sequence, of the liver, pancreas, spleen, and vertebral bone marrow. All patients had liver biopsy samples scored for hepatic iron grading (0-4) and iron cellular distribution (within hepatocytes only or within both hepatocytes and Kupffer cells).

RESULTS

Liver R2* increased with histological iron grade (R_S=0.58, p<0.001) and correlated with spleen (R_S=0.71, p<0.001) and bone marrow R2* (R_S=0.66, p<0.001), but not with pancreatic R2* (R_S=0.22, p=0.096). Splenic and bone marrow R2* values were also correlated (R_S=0.72, p<0.001). Patients with iron inside Kupffer cells had the highest R2* in liver, spleen and bone marrow.

CONCLUSIONS

Patients with chronic diffuse liver diseases have concomitant hepatic, splenic, and bone marrow iron loading. The highest hepatic iron scores and iron inside Kupffer cells were associated with the highest splenic and bone marrow deposits, suggesting systemic iron accumulation in the mononuclear phagocytic system.

Candida glabrata's recurrent infections: biofilm formation during Amphotericin B treatment

Candida species are responsible for recurrent human infections, mostly in immunocompromised patients, due to their high vulnerability. Candida glabrata has a major role in systemic candidiasis and Amphotericin B (AmB), a polyene only used in hospitals, is frequently used to treat this disease. Lately, however, clinical evidences of Candida recurrent infections during these treatments are being described, probably due to biofilm (re)formation during this therapy. Thus, this work aims at inferring if C. glabrata biofilms are still being formed during AmB treatment. For that, C. glabrata biofilms were formed in the presence of AmB and analysed by dry weight. Matrix composition was analysed quantifying carbohydrates and, specifically, β-1,3 glucans. Results demonstrated that, although in a lesser extent, C. glabrata is able to develop biofilms in the presence of AmB, with a thick extracellular matrix, with an increase on carbohydrates, especially β-1,3 glucans. Therefore, it is confirmed that complex biofilms of C. glabrata can be formed during an AmB treatment.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study shows new insights regarding recurrent candidiasis. The authors demonstrated that Amphotericin B did not totally prevent the development of biofilms during Candida glabrata's infection treatment and that the change in the biofilm matrices may have a high responsibility for the fail in the treatment of systemic candidiasis.

Chitosan nanoparticles as alternative anti-staphylococci agents: Bactericidal, antibiofilm and antiadhesive effects

Chitosan is a biocompatible, bioactive, non-toxic polymer that due to these characteristics has been widely used as a carrier for targeted delivery of bioactive molecules. In recent years, and considering that chitosan has a strong antimicrobial potential, the scientific community's focus has shifted onto the possible antimicrobial activity of chitosan nanoparticles. With this in mind, the aim of this work was to produce low molecular weight chitosan nanoparticles, through the ionic gelation method and characterize their potential biological activity against three staphylococci (MSSA, MRSA and MRSE) in planktonic and sessile environments. The chitosan nanoparticles produced had an average size of 244±12nm, an average charge of 17.3±1.4mV and had a MIC of 1.25mg/mL for all tested microorganisms. Bactericidal activity was only registered for MSSA and MRSA with the time-inhibition curves showing bactericidal activity within 1h. Assays regarding chitosan nanoparticles' impact upon sessile populations showed that they were effective in preventing MRSE adhesion and highly effective in reducing MRSA and MSSA biofilm formation.

Insights into chitosan antibiofilm activity against methicillin-resistant Staphylococcus aureus

AIMS

Chitosan is a natural compound that has been validated as a viable antimicrobial agent against Staphylococcus aureus. With this work we sought to evaluate the planktonic and sessile sensitivity of methicillin-resistant S. aureus to chitosan's activity and evaluate if methicillin-resistant S. aureus (MRSA) would be more or less sensitive to chitosan's activity than methicillin-sensitive S. aureus (MSSA).

METHODS AND RESULTS

A group comprised of reference strains and clinical multiresistant isolates of MSSA and MRSA were used. Methicilin resistance effect upon chitosan activity was assessed in planktonic setting and in different phases of sessile colonization, namely adhesion, biofilm formation and mature biofilm through biomass and metabolism inhibition. The results obtained showed that S. aureus methicillin resistance mechanism did not impair chitosan's activity as the highest bacterial susceptibility was registered for MRSA. Chitosan was highly effective in inhibiting MSSA and MRSA strains in both planktonic and sessile settings with biofilm inhibition percentages reaching as high as 90% for MRSA.

CONCLUSIONS

Staphylococcus aureus methicillin resistance did not impair chitosan's antimicrobial and antibiofilm activities and MRSA and MSSA were inhibited both in planktonic and sessile settings at low concentrations with great efficacy.

SIGNIFICANCE AND IMPACT OF THE STUDY

Considering the obtained results chitosan shows potential as an alternative for the control of biofilm-related recalcitrant MRSA infections.

Gender Difference Among Admitted Patients with Bipolar Disorder in a Psychiatric Service During a Three-year Period

Introduction

Gender differences in bipolar disorder are becoming apparent, but have been less studied compared with major depression. The presentation, clinical features, course and evolution of bipolar disorder differ between men and women. Research data on these differences will help determine whether gender is important in influencing illness variables.

Objectives

Determine whether men and women with bipolar disorder have statistical significant differences in socio-demographic and clinical data.

Methods

Charts of all patients with a diagnosis of bipolar disorder admitted in the Coimbra Hospital and Universitary Center over a three-year period (between 2013 and 2015) were reviewed to gather data on socio-demographic, clinical and psychopathological variables to assess differences across genders. Statistical analysis of data with “SPSS21”.

Results

During a three-year period, 189 patients were admitted with bipolar disorder, the majority were female patients, with ages between 21 and 84 years old. The authors will analyse if there is any statistical significant difference between gender in the rate of bipolar I or II diagnoses, age at onset, symptom presentation, delay in diagnoses, number of depressive, or manic episodes, hospitalisations, involuntarily admissions, number of suicide attempts, co-morbidity rates, negative life events, family history and treatment options. Sociodemograpic characteristics will also be analysed.

Conclusion

Gender differences in bipolar disorder is a controversial issue in the literature. The importance of gender on the course and outcome in bipolar disorder has been widely acknowledged. The limited data suggest that the prevalence is similar between sexes but that the course of illness may be different.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Pb low doses induced genotoxicity in Lactuca sativa plants

Soil and water contamination by lead (Pb) remains a topic of great concern, particularly regarding crop production. The admissible Pb values in irrigation water in several countries range from ≈0.1 to ≈5 mg L-1. In order to evaluate putative effects of Pb within legal doses on crops growth, we exposed Lactuca sativa seeds and seedlings to increasing doses of Pb(NO3)2 up to 20 mg L-1. The OECD parameter seed germination and seedling/plant growth were not affected by any of the Pb-concentrations used. However, for doses higher than 5 mg L-1 significant DNA damage was detected: Comet assay detected DNA fragmentation at ≥ 5 mg L-1 and presence of micronuclei (MN) were detected for 20 mg L-1. Also, cell cycle impairment was observed for doses as low as 0.05 mg L-1 and 0.5 mg L-1 (mostly G2 arrest). Our data show that for the low doses of Pb used, the OECD endpoints were not able to detect toxicity, while more sensitive endpoints (related with DNA damage and mitotic/interphase disorders) identified genotoxic and cytostatic effects. Furthermore, the nature of the genotoxic effect was dependent on the concentration. Finally, we recommend that MN test and the comet assay should be included as sensitive endpoints in (eco)toxicological assays.

Phenolic Compounds and Antioxidant Activity of Olea europaea L. Fruits and Leaves

Extracts of leaves, fruits and seeds of olive tree cultivars of Trás-os-Montes e Alto Douro (Portugal) were analysed by reverse phase HPLC with diode array detection and mass spectrometry (MS). This methodology allowed the identification of some common phenolic compounds, namely, verbascoside, rutin, luteolin-7-glucoside, oleuropein and hydroxytyrosol. Moreover the hyphenation of HPLC with MS enabled the identification of nüzhenide in olive seeds. An oleuropein glucoside was also detected in olive tree leaves. The total phenolic content was determined with the Folin Denis reagent and the total antioxidant activity with the ABTS method. There is a correlation between total antioxidant activity and total phenolic content with the exception of the seed extracts analysed. The apparent high antioxidant activity of seed extracts may be due to nüzhenide, a secoiridoid that is the major phenolic component of olive seeds. These results suggest a possible application of olive seeds as sources of natural antioxidants.