A Case Report of Pulmonary Embolectomy Under Cardiopulmonary Bypass in a Patient with Intracranial Hemorrhage and History of Heparin-Induced Thrombocytopenia

Pulmonary embolism is a common complication after intracranial hemorrhage. As thrombolysis is contraindicated in this situation, surgical pulmonary embolectomy may be indicated in case of high-risk pulmonary embolism but requires transient anticoagulation with heparin during cardiopulmonary bypass. We report the case of a patient with a history of heparin-induced thrombocytopenia who presented with a high-risk pulmonary embolism 10 days after the spontaneous onset of a voluminous intracerebral hematoma. Despite high doses of heparin required to run the cardiopulmonary bypass and subsequent anticoagulation by danaparoid sodium, the brain hematoma remained stable and the patient was discharged without complications 30 days after surgery.

Factors Influencing Anti-Xa Assays: A Multicenter Prospective Study in Critically Ill and Noncritically Ill Patients Receiving Unfractionated Heparin

BACKGROUND

 The presence of dextran sulfate (DS) in reagents and the type of blood collection tube (citrate/citrated-theophylline-adenosine-dipyridamole [CTAD]) can lead to discrepancies between unfractionated heparin (UFH) anti-Xa levels.

OBJECTIVES

 To evaluate the extent of the effect (1) of different reagents containing or not containing DS and (2) of the blood collection tubes, on UFH anti-Xa levels, in various clinical situations (NCT04700670).

METHODS

 We prospectively included patients from eight centers: group (G)1, cardiopulmonary bypass (CPB) after heparin neutralization (n = 39); G2, cardiothoracic intensive care unit (ICU) after CPB (n = 35); G3, medical ICU (n = 53); G4, other medical inpatients (n = 38). Blood was collected into citrated and CTAD tubes. Chromogenic anti-Xa assays were centrally performed, using seven reagent/analyzer combinations including two without DS. The association between anti-Xa levels and covariates was tested using a linear mixed-effects model.

RESULTS

 We analyzed 4,546 anti-Xa values from 165 patients. Median anti-Xa levels were systematically higher with reagents containing DS, whatever the patient group, with the greatest effect observed in G1 (0.32 vs. 0.05 IU/mL). Anti-Xa levels were slightly higher in CTAD than in citrate samples, irrespective of the assay. The model showed: (1) a significant dextran-patient group interaction (p < 0.0001), the effect of DS on anti-Xa levels varying from 30.9% in G4 to 296% in G1, and (2) a significant effect of CTAD, varying between patient groups (p = 0.0302).

CONCLUSION

 The variability of anti-Xa levels with a great overestimation of the values, using a reagent containing DS, can lead to different treatment decisions, especially after heparin neutralization by protamine. Clinical consequences of these differences remain to be demonstrated.

Unchanged Characteristics and Survival among Critically Ill COVID-19 Patients during First, Second, and Third Waves: A Prospective Observational Cohort

BACKGROUND

This study was carried out to compare characteristics and outcomes in patients with acute respiratory failure related to COVID-19 during first, second, and third waves.

METHODS

We included consecutive adults admitted to the intensive care unit between March 2020 and July 2021. We compared three groups defined by the epidemic intake phase: waves 1 (W1), 2 (W2), and 3 (W3).

RESULTS

We included 289 patients. Two hundred and eight (72%) patients were men with a median age of 63 years (IQR: 54-72), of whom 68 (23.6%) died in hospital. High-flow nasal oxygen (HFNO) was inversely associated with the need for invasive mechanical ventilation (MV) in multivariate analysis (p = 0.003) but not dexamethasone (p = 0.25). The day-90 mortality rate did not vary from W1 (27.4%) to W2 (23.9%) and W3 (22%), p = 0.67. By multivariate analysis, older age (odds ratio [OR]: 0.94/year, p &lt; 0.001), immunodeficiency (OR: 0.33, p = 0.04), acute kidney injury (OR: 0.26, p &lt; 0.001), and invasive MV (OR: 0.13, p &lt; 0.001) were inversely associated with higher day-90 survival as opposed to the use of intermediate heparin thromboprophylaxis dose (OR: 3.21, p = 0.006). HFNO use and dexamethasone were not associated with higher day-90 survival (p = 0.24 and p = 0.56, respectively).

CONCLUSIONS

In patients with acute respiratory failure due to COVID-19, survival did not change between first, second, and third waves while the use of invasive MV decreased. HFNO or intravenous steroids were not associated with better outcomes, whereas the use of intermediate dose of heparin for thromboprophylaxis was associated with higher day-90 survival. Larger multicentric studies are needed to confirm our findings.

Faceting the post-disaster built heritage reconstruction process within the digital twin framework for Notre-Dame de Paris

April 15th, 2019: Notre-Dame Cathedral in Paris was burning, the spire collapsed on the nave, vaults crumbled and most of the timber roof was gone. In the post-disaster context, the authenticity and the monitoring of the archaeological remains are crucial for their potential reuse during reconstruction. This paper analyzes the collapsed transverse arch from the nave of Notre-Dame as a case study of reconstruction, using the digital twin framework. We propose four facets for the digital twin experiment-physical anastylosis, reverse engineering, spatio-temporal tracking of assets, and operational research-that are described in detail, while being assembled to support a hybrid reconstruction hypothesis. The digital twin can realize the parallel unfolding of physical-native and digital-native processes, while acquiring and storing heterogeneous information as semantically structured data. The results demonstrate that the proposed modeling method facilitates the formalization and validation of the reconstruction problem and increases solutions performances. As result, we present a digital twin framework application ranging from acquisition to data processing that informs a successful hybrid reconstruction hypothesis.

Empirical Antibiotic Therapy for Gram-Negative Bacilli Ventilator-Associated Pneumonia: Observational Study and Pharmacodynamic Assessment

Background: Strong evidence suggests a correlation between pharmacodynamics (PD) index and antibiotic efficacy while dose adjustment should be considered in critically ill patients due to modified pharmacokinetic (PK) parameters and/or higher minimum inhibitory concentrations (MICs). This study aimed to assess pharmacodynamic (PD) target attainment considering both antibiotics serum concentrations and measured MICs in these patients. Method: A multicentric prospective open-label trial conducted in 11 French ICUs involved patients with Gram-negative bacilli (GNB) ventilator-associated pneumonia (VAP) confirmed by quantitative cultures. Results: We included 117 patients. Causative GNBs were P. aeruginosa (40%), Enterobacter spp. (23%), E. coli (20%), and Klebsiella spp. (16%). Hence, 117 (100%) patients received β-lactams, 65 (58%) aminoglycosides, and two (1.5%) fluoroquinolones. For β-lactams, 83% of the patients achieved a Cmin/MIC > 1 and 70% had a Cmin/MIC > 4. In the case of high creatinine clearance (CrCL > 100 mL/min/1.73 m2), 70.4% of the patients achieved a Cmin/MIC ratio > 1 versus 91% otherwise (p = 0.041), and 52% achieved a Cmin/MIC ratio > 4 versus 81% (p = 0.018). For aminoglycosides, 94% of the patients had a Cmax/MIC ratio > 8. Neither β-lactams nor aminoglycosides PK/PD parameters were associated clinical outcomes, but our data suggest a correlation between β-lactams Cmin/MIC and microbiological success. Conclusion: In our ICU patients treated for GNB VAP, using recommended antibiotic dosage led in most cases to PK/PD targets attainment for aminoglycosides and β-lactams. High creatinine clearance should encourage clinicians to focus on PK/PD issues.

Risk Factors and Consequences of Late-Onset Hyperlactatemia After Cardiac Surgery With Cardiopulmonary Bypass: A Single-Center Retrospective Study

OBJECTIVE

Mechanisms and consequences of late-onset hyperlactatemia after cardiac surgery remain unclear. The aim of this study was to identify risk factors and outcomes of late hyperlactatemia, defined as a lactate value ≥3 mmol/L developing in the intensive care unit (ICU) after not being elevated on admission after cardiac surgery with cardiopulmonary bypass.

DESIGN

A retrospective analysis of prospectively collected data.

SETTING

A single-center University Hospital.

PARTICIPANTS

Patients who underwent elective cardiac surgery with cardiopulmonary bypass in 2019 and who had normal lactatemia at ICU admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were divided in 2 groups according to their lactatemia on postoperative day 1 (14.0 ± 3.0 hours after ICU admission): normal lactatemia (control group) and late hyperlactatemia (HL group). Risk factors for late hyperlactatemia were identified using a multivariate analysis, and postoperative outcomes were compared using a composite criterion of severe outcomes. Of the 432 included patients, 37 (8.5%) presented with late hyperlactatemia. Risk factors independently associated with hyperlactatemia were afternoon surgery (odds ratio [OR] 4.24, 95% CI 2.00-9.35), a bleeding >300 mL within the 6 hours after surgery (H6) (OR 3.77, 95% CI 1.71-8.30), and H6 fluid loading >250 mL (OR 2.64, 95% CI 1.22-5.55). Patients with hyperlactatemia presented more frequently with major postoperative complications, including acute kidney injury, and received more frequent red-cell transfusion.

CONCLUSION

The strongest risk factors associated with late-onset hyperlactatemia in the authors' population were afternoon surgery and H6 bleeding >300 mL. Poor postoperative outcomes were more frequent in patients with late hyperlactatemia, even in the absence of early hyperlactatemia or severe obvious condition.

O-267 Uterine volume is dramatically decreased in Stem Cell Hematopoietic Transplantation childhood survivors whatever the conditioning regimen. A case-control MRI study in the L.E.A cohort

Study question

What is the impact of the type of myeloablative conditioning (MAC) regimen applied for hematopoietic stem cell transplantation (HSCT) on uterine volume of childhood leukemia survivors?

Summary answer

Uterine volume is significantly decreased after HSCT. Not only Total Body Irradiation (TBI), but also high-dose chemotherapy-based regimens containing alkylating agents induce uterine damage.

What is known already

Premature ovarian failure after HSCT is well known, as well as the uterine damage induced by TBI on uterine volume. A few studies have reported smaller uterus after HSCT in women treated with chemotherapy only. In these studies, uterus volume was assessed by a transabdominal and/or transvaginal ultrasonography, and primary diagnosis, age at treatment and chemotherapy regimen were heterogeneous. These preliminary results suggested that alkylating agents could induce uterine damage, as well as they induce fibrosis and vascular damage in ovarian stroma. The impact of chemotherapy on myometrium and uterus is still few investigated.

Study design, size, duration

A prospective multicentric national study was conducted between 2017, November and 2021, June in 16 University Teaching Hospitals that are following more than 4 500 childhood acute leukemia survivors enrolled in the L.E.A cohort. We included 88 adult women treated for a childhood acute leukemia with HSCT and who agreed a pelvic MRI assessment. Every case was matched 1:1 to control women who underwent MRI for benign ovarian cysts or benign pelvic pathology.

Participants/materials, setting, methods

Pelvic MRI scans were performed with a 1.5-T or 3T magnetic resonance scanner, including diffusion-weighted imaging sequences. Scans were centralized for a double-blinded lecture by two radiologists. The main outcome was the uterine volume. The secondary outcomes were uterine body-to-cervix ratio and apparent diffusion coefficient (ADC). Univariate and multivariate analyses have investigated the association of clinical and imaging variables with conditioning regimen and age at HSCT.

Main results and the role of chance

The mean age in HSCT group was 26.5 + 6.3 years. Mean age at HSCT was 9.1 + 0.3 years with a mean follow-up of 16.4 + 0.5 years. Among the 88 women included in HSCT group, two groups of conditioning regimens have been compared to the control group: a chemotherapy-only MAC regimen group with high dose of alkylating agents (n = 34) and one TBI-based regimen group (n = 52). Two MRI scans were not available. Among HSCT group, 75 women were considered as “normally impregnated” by estrogens, by hormone replacement therapy (HRT) for premature ovarian insufficiency (POI) or thanks to a residual ovarian function. Uterine volume was significantly decreased both after chemotherapy-only MAC regimen and after TBI, with respectively 45.3 + 5.6 and 19.6 + 1.9 mL Vs 79.7 + 3.3 mL in control population (p &lt; 0.01). In chemotherapy-only MAC regimen group, uterine volume was dramatically decreased in POI women without HRT compared to those having a hormonal impregnation (15.2 + 2.6 Vs 49.3 + 6 mL, p &lt; 0.05). In contrast, after TBI, uterine volume was similar in all women, with no positive effect of HRT on uterine volume (respectively 16.3 + 2.6 Vs 20.1 + 2.2 mL).

Limitations, reasons for caution

The number of pregnancies obtained spontaneously or after oocyte donation in our study population was too low to evaluate the obstetrical impact of uterine damage caused by non-TBI regimens.

Wider implications of the findings

Our results provide strong evidence that a MAC regimen containing high dose of alkylating agents could induce uterine damage. In these sub-group of women, HRT increases the volume of the uterus compared to non-treated women. After TBI, uterine volume is dramatically decreased, with no benefit of HRT on it.

Trial registration number

NCT 03583294

Characteristics and Outcomes of Patients in the ICU With Respiratory Syncytial Virus Compared With Those With Influenza Infection: A Multicenter Matched Cohort Study

BACKGROUND

The characteristics and outcomes of adult patients with respiratory syncytial virus (RSV) infection who require ICU admission are poorly defined. Although several studies in adults with RSV infection have been published in recent years, they did not focus specifically on patients with critical illness.

RESEARCH QUESTION

What are the characteristics and outcomes of adult patients in the ICU with RSV infection and how do they compare with those of patients in the ICU with influenza infection?

STUDY DESIGN AND METHODS

This retrospective, multicenter study in France and Belgium (17 sites) compared the characteristics and outcomes of adult patients in the ICU with RSV infection vs those with influenza infection between November 2011 and April 2018. Each patient with RSV infection was matched by institution and date of diagnosis with a patient with influenza infection. In-hospital mortality was compared between the two groups, with adjustment for prognostic factors in a multivariate model (sex, age, main underlying conditions, and concurrent bloodstream infection).

RESULTS

Data from 618 patients (309 with RSV infection and 309 with influenza infection) were analyzed. Patients with RSV infection were significantly more likely to have an underlying chronic respiratory condition (60.2% vs 40.1%; P < .001) and to be immunocompromised (35% vs 26.2%; P = .02) than patients with influenza infection. Several differences in clinical signs and biological data at diagnosis were found between the groups. In-hospital mortality was not significantly different between the two groups (23.9% in the RSV group vs 25.6% in the influenza group; P = .63), even after adjustment for prognostic factors in a multivariate model.

INTERPRETATION

Adult patients in the ICU with RSV infection differ from adult patients in the ICU with influenza in terms of comorbidities and characteristics at diagnosis. RSV infection was associated with high in-hospital mortality, approaching 25%. In multivariate analysis, RSV infection was associated with a similar odds of in-hospital death compared with influenza infection.

Postextubation Stridor in Severe COVID-19

BACKGROUND

During the coronavirus disease 2019 (COVID-19) pandemic, 60-80% of patients admitted to ICU require mechanical ventilation for respiratory distress. We aimed to compare the frequency of postextubation stridor (PES) and to explore risk factors in COVID-19 subjects compared to those without COVID-19.

METHODS

We performed an observational retrospective study on subjects admitted for severe COVID-19 requiring mechanical ventilation > 48 h during the first and second waves in 2020 and compared these subjects to historical controls without COVID-19 who received mechanical ventilation > 48 h between 2016-2019. The primary outcome was the frequency of PES, defined as audible stridor within 2 h following extubation.

RESULTS

Of the 134 subjects admitted with severe COVID-19 requiring mechanical ventilation, 96 were extubated and included and compared to 211 controls. The frequency of PES was 22.9% in the COVID-19 subjects and 3.8% in the controls (P < .001). Factors independently associated with PES were having COVID-19 (odds ratio 3.72, [95% CI 1.24-12.14], P = .02), female sex (odds ratio 5.77 [95% CI 2.30-15.64], P < .001), and tube mobilization or re-intubation or prone positioning (odds ratio 3.01 [95% CI 1.04-9.44], P = .047) after adjustment on Simplified Acute Physiology Score II expanded). During the first wave, PES was significantly more common in subjects with a positive SARS-CoV-2 RT-PCR test on tracheal samples on the day of extubation (73.3% vs 24.3%, P = .018).

CONCLUSIONS

PES affected nearly one-quarter of subjects with COVID-19, a proportion significantly higher than that seen in controls. Independent risk factors for PES were COVID-19, female sex, and tube mobilization or re-intubation or prone positioning. PES was associated with persistent viral shedding at the time of extubation.

The course of primary progressive aphasia diagnosis: a cross-sectional study

Background

The primary progressive aphasia (PPA) diagnosis trajectory is debated, as several changes in diagnosis occur during PPA course, due to phenotype evolution from isolated language alterations to global cognitive impairment.

The goal of the present study, based on a French cohort, was to describe the demographics and the evolution of subjects with (PPA) in comparison with Alzheimer’s disease (AD) on a period of 7 years.

Methods

We conducted a repeated cross-sectional study. The study population comprised individuals with PPA and AD diagnosis (N=167,191) from 2010 to 2016 in the French National data Bank (BNA). Demographic variables, MMSE scores, diagnosis status at each visit and prescribed treatments were considered.

Results

From 2010 to 2016, 5186 patients were initially diagnosed with PPA, 162,005 with AD. Compared to AD subjects, significant differences were found concerning age (younger at first diagnosis for PPA), gender (more balanced in PPA), education level (higher in PPA) and MMSE score (higher of 1 point in PPA).

Percentage of pending diagnosis, delay between first consultation and first diagnosis and the number of different diagnoses before the diagnosis of interest were significantly higher in PPA group compared to AD group. Pharmacological and non-pharmacological treatments were significatively more recommended following PPA than AD diagnosis.

Conclusion

This study improves the knowledge of PPA epidemiology and has the potential to help adopting appropriate public health service policies. It supports the hypothesis that PPA is diagnosed later than AD. The PPA diagnosis increases the prescription of non-pharmacological treatments, especially speech and language therapy (SLT) that is the main treatment available and most effective when at the initial stage.

Trial registration

ClinicalTrials.gov identifier NCT03687112

Supplementary Information

The online version contains supplementary material available at 10.1186/s13195-022-01007-6.

Connaissances des médecins généralistes sur les modalités de prescription de l'orthophonie

INTRODUCTION

General practitioners are the first prescribers of speech therapy in France, a country in which speech therapists can practice only on medical prescription. The objective of this study was to measure general practioner's knowledge on means of prescribing speech therapy.

METHOD

Cross-sectional study by self-questionnaires for general practitioners and residents in general practice in France. The test assessed five types of knowledge conducive to correct prescription of speech therapy: requirements for prescription, indications, prescription wording, ages of treatment eligibility, and reimbursement. The questionnaires were tested on an expert population, whose median score was used as a cut-off to separate doctors who knew the modalities of speech therapy prescription from those whose knowledge was insufficient. The characteristics differentiating the two groups were compared by multiple logistic regression.

RESULTS

Five hundred and three general practitioners and five hundred and two residents in general medicine were included; 82.3% of the physicians having written a thesis and 86.2% of the residents had insufficient knowledge of the modalities of speech therapy prescription. Age, number of years since acquisition of a medical diploma and urban practice all had a negative impact on general practitioners' knowledge of speech therapy.

CONCLUSION

French general practitioners' knowledge of speech therapy prescription seems insufficient. It is consequently necessary to improve the initial and continuing training of doctors. Collaborative work between general practitioners and speech therapists should be carried on, developed and strengthened.

Tocilizumab plus dexamethasone versus dexamethasone in patients with moderate-to-severe COVID-19 pneumonia: A randomised clinical trial from the CORIMUNO-19 study group

BACKGROUND

In moderate-to-severe COVID-19 pneumonia, dexamethasone (DEX) and tocilizumab (TCZ) reduce the occurrence of death and ventilatory support. We investigated the efficacy and safety of DEX+TCZ in an open randomized clinical trial.

METHODS

From July 24, 2020, through May 18, 2021, patients with moderate-to-severe COVID-19 pneumonia requiring oxygen (>3 L/min) were randomly assigned to receive DEX (10 mg/d 5 days tapering up to 10 days) alone or combined with TCZ (8 mg/kg IV) at day 1, possibly repeated with a fixed dose of 400 mg i.v. at day 3. The primary outcome was time from randomization to mechanical ventilation support or death up to day 14, analysed on an intent-to-treat basis using a Bayesian approach. ClinicalTrials.gov number, NCT04476979.

FINDINGS

A total of 453 patients were randomized, 3 withdrew consent, 450 were analysed, of whom 226 and 224 patients were assigned to receive DEX or TCZ+DEX, respectively. At day 14, mechanical ventilation or death occurred in 32/226 (14%) and 27/224 (12%) in the DEX and TCZ+DEX arms, respectively (hazard ratio [HR] 0·85, 90% credible interval [CrI] 0·55 to 1·31). At day 14, the World health Organization (WHO) clinical progression scale (CPS) was significantly improved in the TCZ+DEX arm (OR 0·69, 95% CrI, 0·49 to 0.97). At day 28, the cumulative incidence of oxygen supply independency was 82% in the TCZ+DEX arms and 72% in the DEX arm (HR 1·36, 95% CI 1·11 to 1·67). On day 90, 24 deaths (11%) were observed in the DEX arm and 18 (8%) in the TCZ+DEX arm (HR 0·77, 95% CI 0·42-1·41). Serious adverse events were observed in 25% and 21% in DEX and TCZ+DEX arms, respectively.

INTERPRETATION

Mechanical ventilation need and mortality were not improved with TCZ+DEX compared with DEX alone. The safety of both treatments was similar. However, given the wide confidence intervals for the estimate of effect, definitive interpretation cannot be drawn.

FUNDING

Programme Hospitalier de Recherche Clinique [PHRC COVID-19-20-0151, PHRC COVID-19-20-0029], Fondation de l'Assistance Publique - Hôpitaux de Paris (Alliance Tous Unis Contre le Virus) and from Fédération pour la Recherche Médicale" (FRM). Tocilizumab was provided by Roche.

Association of ventilator type with hospital mortality in critically ill patients with SARS-CoV2 infection: a prospective study

Background

To evaluate the association between ventilator type and hospital mortality in patients with acute respiratory distress syndrome (ARDS) related to COVID-19 (SARS-CoV2 infection), a single-center prospective observational study in France.

Results

We prospectively included consecutive adults admitted to the intensive care unit (ICU) of a university-affiliated tertiary hospital for ARDS related to proven COVID-19, between March 2020 and July 2021. All patients were intubated. We compared two patient groups defined by whether an ICU ventilator or a less sophisticated ventilator such as a sophisticated turbine-based transport ventilator was used. Kaplan–Meier survival curves were plotted. Cox multivariate regression was performed to identify associations between patient characteristics and hospital mortality. We included 189 patients (140 [74.1%] men) with a median age of 65 years [IQR, 55–73], of whom 61 (32.3%) died before hospital discharge. By multivariate analysis, factors associated with in-hospital mortality were age ≥ 70 years (HR, 2.11; 95% CI, 1.24–3.59; P = 0.006), immunodeficiency (HR, 2.43; 95% CI, 1.16–5.09; P = 0.02) and serum creatinine ≥ 100 µmol/L (HR, 3.01; 95% CI, 1.77–5.10; P < 0.001) but not ventilator type. As compared to conventional ICU (equipped with ICU and anesthesiology ventilators), management in transient ICU (equipped with non-ICU turbine-based ventilators) was associated neither with a longer duration of invasive mechanical ventilation (18 [IQR, 11–32] vs. 21 [13–37] days, respectively; P = 0.39) nor with a longer ICU stay (24 [IQR, 14–40] vs. 27 [15–44] days, respectively; P = 0.44).

Conclusions

In ventilated patients with ARDS due to COVID-19, management in transient ICU equipped with non-ICU sophisticated turbine-based ventilators was not associated with worse outcomes compared to standard ICU, equipped with ICU ventilators. Although our study design is not powered to demonstrate any difference in outcome, our results after adjustment do not suggest any signal of harm when using these transport type ventilators as an alternative to ICU ventilators during COVID-19 surge.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-00981-2.

Sarilumab in adults hospitalised with moderate-to-severe COVID-19 pneumonia (CORIMUNO-SARI-1): An open-label randomised controlled trial

Background

Patients with COVID-19 pneumonia can have increased inflammation and elevated cytokines, including interleukin (IL)-6, which might be deleterious. Thus, sarilumab, a high-affinity anti-IL-6 receptor antibody, might improve the outcome of patients with moderate-to-severe COVID-19 pneumonia.

Methods

We did a multicentric, open-label, Bayesian randomised, adaptive, phase 2/3 clinical trial, nested within the CORIMUNO-19 cohort, to test a superiority hypothesis. Patients 18 years or older hospitalised with COVID-19 in six French centres, requiring at least 3L/min of oxygen but without ventilation assistance and a WHO Clinical Progression Scale [CPS] score of 5 were enrolled. Patients were randomly assigned (1:1) via a web-based system, according to a randomisation list stratified on centre and with blocks randomly selected among 2 and 4, to receive usual care plus 400 mg of sarilumab intravenously on day 1 and on day 3 if clinically indicated (sarilumab group) or usual care alone (usual care group). Primary outcomes were the proportion of patients with WHO-CPS scores greater than 5 on the 10-point scale on day 4 and survival without invasive or non-invasive ventilation at day 14. This completed trial is closed to new participants and is registered with ClinicalTrials.gov, NCT04324073.

Findings

165 patients were recruited from March 27 to April 6, 2020, and 148 patients were randomised (68 patients to the sarilumab group and 80 to the usual care group) and followed up for 90 days. Median age was 61·7 years [IQR 53·0–71·1] in the sarilumab group and 62·8 years [56·0–71·7] in the usual care group. In the sarilumab group 49 (72%) of 68 were men and in the usual care group 59 (78%) of 76 were men. Four patients in the usual care group withdrew consent and were not analysed. 18 (26%) of 68 patients in the sarilumab group had a WHO-CPS score greater than 5 at day 4 versus 20 (26%) of 76 in the usual care group (median posterior absolute risk difference 0·2%; 90% credible interval [CrI] −11·7 to 12·2), with a posterior probability of absolute risk difference greater than 0 of 48·9%. At day 14, 25 (37%) patients in the sarilumab and 26 (34%) patients in the usual care group needed ventilation or died, (median posterior hazard ratio [HR] 1·10; 90% CrI 0·69–1·74) with a posterior probability HR greater than 1 of 37·4%. Serious adverse events occurred in 27 (40%) patients in the sarilumab group and 28 (37%) patients in the usual care group (p=0·73).

Interpretation

Sarilumab treatment did not improve early outcomes in patients with moderate-to-severe COVID-19 pneumonia. Further studies are warranted to evaluate the effect of sarilumab on long-term survival.

Funding

Assistance publique—Hôpitaux de Paris

How Dominant Hand and Foot Dexterity May Reveal Dementia Onset: A Motor and Cognitive Dual-Task Study

The combined provision of an arising number of dementia cases, and the substantial absence of effective treatments, led the scientific community toward the identification of early phases of this condition. Such an effort aims at the recognition of therapeutic windows and the characterization of the disease's different grades. In the last years, Motor and Cognitive Dual-Tasks (MCDT) have been widely used to address the early diagnosis of several neurocognitive disorders, among which dementia. Here we present different protocols: the walking MCDT, the toe-tapping MCDT, and the forefinger-tapping MCDT. Moreover, each task has been performed under different cognitive conditions: no cognitive effort, counting backwards by 1, 3, and 7. In this work, we report the results obtained through the combination of different motor and cognitive tasks, and we present 2 brand-new MCDT protocols, attempting to identify a sweet-spot for early diagnosis of dementia.

Sex ratio in dementia with Lewy bodies balanced between Alzheimer's disease and Parkinson's disease dementia: a cross-sectional study

Background

Gender distribution varies across neurodegenerative disorders, with, traditionally, a higher female frequency reported in Alzheimer’s disease (AD) and a higher male frequency in Parkinson’s disease (PD). Conflicting results on gender distribution are reported concerning dementia with Lewy bodies (DLB), usually considered as an intermediate disease between AD and PD. The aim of the present study was to investigate gender differences in DLB in French specialized memory settings using data from the French national database spanning from 2010 to 2015 and to compare sex ratio in DLB with that in AD, Parkinson’s disease dementia (PDD), and PD. Our hypothesis was that there is a balanced sex ratio in DLB, different from that found in AD and PD.

Methods

We conducted a repeated cross-sectional study. The study population comprised individuals with a DLB, AD, PDD, or PD diagnosis according to the International Classification of Diseases, Tenth Revision, in the French National Alzheimer Database between 2010 and 2015. Sex ratio and demographic data were compared using multinomial logistic regression and a Bayesian statistical model.

Results

From 2010 to 2015 in French specialized memory settings, sex ratios (female percent/male percent) were found as follows: 1.21 (54.7%/45.3%) for DLB (n = 10,309), 2.34 (70.1%/29.9%) for AD (n = 135,664), 0.76 (43.1%/56.9%) for PD (n = 8744), and 0.83 (45.4%/54.6%) for PDD (n = 3198). Significant differences were found between each group, but not between PDD and PD, which had a similar sex ratio.

Conclusions

This large-sample prevalence study confirms the balanced gender distribution in the DLB population compared with AD and PD-PDD. Gender distribution and general demographic characteristics differed between DLB and PDD. This is consistent with the hypothesis that DLB is a distinct disease with characteristics intermediate between AD and PD, as well as with the hypothesis that DLB could have at least partially distinct neuropathological correlates.

Impact of transfusion on patients with sepsis admitted in intensive care unit: a systematic review and meta-analysis

Red blood cell transfusion (RBCT) threshold in patients with sepsis remains a matter of controversy. A threshold of 7 g/dL for stabilized patients with sepsis is commonly proposed, although debated. The aim of the study was to compare the benefit and harm of restrictive versus liberal RBCT strategies in order to guide physicians on RBCT strategies in patients with severe sepsis or septic shock. Four outcomes were assessed: death, nosocomial infection (NI), acute lung injury (ALI) and acute kidney injury (AKI). Studies assessing RBCT strategies or RBCT impact on outcome and including intensive care unit (ICU) patients with sepsis were assessed. Two systematic reviews were achieved: first for the randomized controlled studies (RCTs) and second for the observational studies. MEDLINE, EMBASE, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Clinical Trials.gov were analyzed up to March 01, 2015. Der Simonian and Laird random-effects models were used to report pooled odds ratios (ORs). Subgroup analyses and meta-regressions were performed to explore studies heterogeneity. One RCT was finally included. The restrictive RBCT strategy was not associated with harm or benefit compared to liberal strategy. Twelve cohort studies were included, of which nine focused on mortality rate. RBCT was not associated with increased mortality rate (overall pooled OR was 1.10 [0.75, 1.60]; I 2 = 57%, p = 0.03), but was associated with the occurrence of NI (2 studies: pooled OR 1.25 [1.04-1.50]; I 2 = 0%, p = 0.97), the occurrence of ALI (1 study: OR 2.75 [1.22-6.37]; p = 0.016) and the occurrence of AKI (1 study: OR 5.22 [2.1-15.8]; p = 0.001). Because there was only one RCT, the final meta-analyses were only based on the cohort studies. As a result, the safety of a RBCT restrictive strategy was confirmed, although only one study specifically focused on ICU patients with sepsis. Then, RBCT was not associated with increased mortality rate, but was associated with increased in occurrence of NI, ALI and AKI. Nevertheless, the data on RBCT in patients with sepsis are sparse and the high heterogeneity between studies prevents from drawing any definitive conclusions.

Olfaction, émotions et comportements

Le nez a ses raisons que la raison ignore. Les émotions olfactives sont souvent inconscientes et vont pourtant diriger nombreux de nos comportements. Ce lien étroit entre émotion et olfaction est dû au fait que certaines régions cérébrales sont à la fois impliquées dans les processus olfactifs et émotionnels (cortex frontal et amygdale). Dans les pathologies neurodégénératives, dont la maladie d’Alzheimer (MA), ces structures vont être atteintes à des stades plus ou moins sévères de la maladie. Au-delà d’une aide au diagnostic précoce, nous avons montré que l’utilisation d’odorants pourrait aider au diagnostic différentiel entre certains troubles de l’humeur et la maladie d’Alzheimer . Sentir et ressentir, humer et humeur : la langue française nous apporte déjà des preuves d’un lien étroit entre nos émotions et notre olfaction. De manière objective nous avons mis en évidence que les odorants étaient des générateurs d’émotion puissants et stables . Ainsi les odeurs pourraient constituer une alternative non pharmacologique de prise en charge des troubles émotionnels de manière pratique, cette présentation abordera, en premier lieu, le lien précoce entre atteinte olfactive et psycho-comportementale dans la maladie d’Alzheimer puis l’intérêt de la stimulation olfactive dans la prise en charge non médicamenteuse des perturbations émotionnelles et comportementales dans cette pathologie. Pour finir, nous nous interrogerons sur l’apport de l’étude de l’olfaction dans la prise en charge des principaux syndromes émotionnels et thymiques du champ de la pathologie psychiatrique.

Intravascular Complications of Central Venous Catheterization by Insertion Site

BACKGROUND

Three anatomical sites are commonly used to insert central venous catheters, but insertion at each site has the potential for major complications.

METHODS

In this multicenter trial, we randomly assigned nontunneled central venous catheterization in patients in the adult intensive care unit (ICU) to the subclavian, jugular, or femoral vein (in a 1:1:1 ratio if all three insertion sites were suitable [three-choice scheme] and in a 1:1 ratio if two sites were suitable [two-choice scheme]). The primary outcome measure was a composite of catheter-related bloodstream infection and symptomatic deep-vein thrombosis.

RESULTS

A total of 3471 catheters were inserted in 3027 patients. In the three-choice comparison, there were 8, 20, and 22 primary outcome events in the subclavian, jugular, and femoral groups, respectively (1.5, 3.6, and 4.6 per 1000 catheter-days; P=0.02). In pairwise comparisons, the risk of the primary outcome was significantly higher in the femoral group than in the subclavian group (hazard ratio, 3.5; 95% confidence interval [CI], 1.5 to 7.8; P=0.003) and in the jugular group than in the subclavian group (hazard ratio, 2.1; 95% CI, 1.0 to 4.3; P=0.04), whereas the risk in the femoral group was similar to that in the jugular group (hazard ratio, 1.3; 95% CI, 0.8 to 2.1; P=0.30). In the three-choice comparison, pneumothorax requiring chest-tube insertion occurred in association with 13 (1.5%) of the subclavian-vein insertions and 4 (0.5%) of the jugular-vein insertions.

CONCLUSIONS

In this trial, subclavian-vein catheterization was associated with a lower risk of bloodstream infection and symptomatic thrombosis and a higher risk of pneumothorax than jugular-vein or femoral-vein catheterization. (Funded by the Hospital Program for Clinical Research, French Ministry of Health; ClinicalTrials.gov number, NCT01479153.).

Ultrasonography for Screening and Follow-Up of Diaphragmatic Dysfunction in the ICU

Purpose:

Reversibility and impact of diaphragmatic dysfunction (DD) are unknown. The principal aim was to describe diaphragmatic function as assessed by ultrasonography during weaning trials.

Materials and Methods:

The present study is a 6-month single-center prospective study. All patients under mechanical ventilation for more than 7 days and eligible for a spontaneous breathing trial (SBT) were enrolled prospectively.

Intervention:

Two blinded ultrasonographers evaluated each hemidiaphragm during SBT. Prevalence of DD among weaning failure and death and interobserver reproducibility have been evaluated.

Results:

The 34 included patients had a mean Simplified Acute Physiology Score version II of 55.7 ± 14 and a median intensive care unit (ICU) stay length of 17 days (13-30). Diaphragmatic dysfunction was found in 13 (38%) patients, on both sides in 8. Bilateral DD resolved before ICU discharge in 5 of the 7 reevaluated patients. No weaning failures were recorded. The ICU mortality was higher in patients with DD (37% vs 5%, P = .048). Mean interobserver agreement rate was 91%. Reproducibility was better with M-mode.

Conclusion:

The ICU-acquired DD usually improves before ICU discharge but might constitute a marker for greater disease severity. The present preliminary results require confirmation in a larger prospective multicenter study.

Can we predict poor hemodynamic tolerance of intermittent hemodialysis with echocardiography in intensive care patients?

OBJECTIVES

Tolerance of intermittent hemodialysis is potentially poor for patients hospitalized in the intensive care unit, particularly those in shock. The aim of this study was to determine whether an evaluation of the hemodynamic state by echocardiography before an intermittent hemodialysis session could predict tolerance during the session.

METHODS

Before an intermittent hemodialysis session, transesophageal echocardiography was performed on sedated patients, and transthoracic echocardiography was performed on nonsedated patients. Poor tolerance during intermittent hemodialysis was defined by the following criteria: greater than 20% decrease in mean arterial pressure, need for fluid loading (≥500 mL), a 15% increase in catecholamine if the dose was stable before the session or doubling the speed of catecholamine infusion if necessary, arrhythmia, and the necessity to stop the session before its prescribed end.

RESULTS

A total of 54 patients were included: 20 (37%) were intubated under controlled mechanical ventilation (group 1) and underwent transesophageal echocardiography; 14 (26%) were intubated under pressure support ventilation (group 2) and underwent transthoracic echocardiography; and 20 (37%) had no ventilation support (group 3). Twenty-four patients (46%) had poor tolerance criteria. A comparison of groups showed no significant difference in tolerance. Similarly, there was no difference with and without ultrafiltration. Increased respiratory variation of the vena cava was not predictive of poor tolerance in groups 1 and 2. In group 3, there was greater variation in patients with poor tolerance. In patients receiving mechanical ventilation, greater respiratory variability of the maximum velocity measured in the pulmonary artery was predictive of poor tolerance.

CONCLUSIONS

The hemodynamic profile of patients receiving mechanical ventilation was unable to predict tolerance of an intermittent hemodialysis session. In patients without mechanical ventilation, hypovolemia before the session appeared to be predictive of poor tolerance.

Noninvasive quantitative assessment of pulmonary blood flow with 18F-FDG PET

Pulmonary blood flow (PBF) is a critical determinant of oxygenation during acute lung injury (ALI). PET/CT with (18)F-FDG allows the assessment of both lung aeration and neutrophil inflammation as well as an estimation of the regional fraction of blood (FB) if compartmental modeling is used to quantify (18)F-FDG pulmonary uptake. The aim of this study was to validate the use of FB to assess PBF, with PET and compartmental modeling of (15)O-H2O kinetics as a reference method, in both control animals and animals with ALI. For the purpose of studying a wide range of PBF values, supine and prone positions and various positive end-expiratory pressures (PEEPs) and tidal volumes (V(T)s) were selected.

METHODS

Pigs were randomized into 3 groups in which ALI was induced by HCl inhalation: pigs studied in the supine position with a low PEEP (5 ± 3 [mean ± SD] cm of H2O; n = 9) or a high PEEP (12 ± 1 cm of H2O; n = 8) and pigs studied in the prone position with a low PEEP (6 ± 3 cm of H2O; n = 9). Also included were a control group that did not have ALI (n = 6) and 2 additional groups (n = 6 each) that had a high V(T) to maintain a transpulmonary pressure of greater than or equal to 35 cm of H2O and that either received HCl inhalation or did not receive HCl inhalation. PBF and FB were measured with PET and compartmental modeling of (15)O-H2O and (18)F-FDG kinetics in 10 lung regions along the anterior-to-posterior lung dimension, and both were expressed in each region as a fraction of their values in the whole lung.

RESULTS

PBF and FB were strongly correlated (R(2) = 0.9), with a slope of the regression line close to unity and a negligible intercept. The mean difference between PBF and FB was 0, and the 95% limits of agreement were -0.035 to 0.035. This good agreement between methods was obtained in both normal and injured lungs and under a wide range of V(T), PEEP, and regional PBF values (7-71 mL/kg, 0-15 cm of H2O, and 24-603 mL·min(-1)·100 mL of lung(-1), respectively).

CONCLUSION

FB assessed with (18)F-FDG is a good surrogate for PBF in both normal animals and animals with ALI. PET/CT has the potential to be used to study ventilation, perfusion, and lung inflammation with a single tracer.

Intra-individual variation of the cuff-leak test as a predictor of post-extubation stridor

BACKGROUND

This was an evaluation of intra-individual variation of the cuff-leak test (ΔCLT) immediately post-intubation and pre-extubation, as a predictor of post-extubation stridor.

METHODS

Prospective, clinical investigation in the ICU of a non-university hospital. CLTs were performed immediately after intubation (T0) and before extubation (T1) to evaluate the differences in cuff leak (ΔCLT = CL(T1) - CL(T0)).

RESULTS

We included 104 mechanically ventilated subjects in the study over a 12-month period. The incidence of post-extubation stridor was 6.7%. Stridor was more common in females of short stature. ΔCLT was considered as significant when CL(T1) - CL(T0) was negative. The sensitivity and the specificity of the test were 86% and 48%, respectively. When we tested the pre-extubation CLT alone with a threshold of 130 mL as a predictor of post-extubation stridor, the sensitivity and the specificity of the test were 86% and 76%, respectively.

CONCLUSIONS

The intra-individual variation of CLT immediately post-intubation and pre-extubation does not improve the accuracy of a standard pre-extubation CLT to predict post-extubation stridor. Moreover, the standard pre-extubation CLT did not appear in our study to be an ideal test to detect post-extubation stridor. Larger studies should be performed before generalizing these preliminary results.

Chronic alcohol exposure, infection, extended circulating white blood cells differentiated by flow cytometry and neutrophil CD64 expression: a prospective, descriptive study of critically ill medical patients

Background

A history of prolonged and excessive consumption of alcohol increases the risk for infections. The goal of this study was to investigate circulating white blood cells (WBC) differentiated by flow cytometry and neutrophil CD64 expression in excessive alcohol drinkers versus abstinent or moderate drinkers, and in those with or without infection, in medical patients admitted to the intensive care unit (ICU).

Methods

All patients admitted between September 2009 and March 2010 with an ICU-stay of 3 days or more were eligible for inclusion. Upon admission, hematological exams were conducted by flow cytometry.

Results

Overall, 281 adult were included, with 37% identified as at-risk drinkers. The only significant difference found in circulating WBC between at-risk and not-at-risk drinkers was a lower number of B lymphocytes in at-risk drinkers (P = 0.002). Four groups of patients were defined: not-at-risk drinkers with no infection (n = 66); not-at-risk drinkers with infection (n = 112); at-risk drinkers with no infection (n = 53); and at-risk drinkers with infection (n = 50). Whilst the presence of infection significantly reduced levels of noncytotoxic and cytotoxic T lymphocytes and significantly increased levels of CD16^– monocytes in not-at-risk drinkers, with variation related to infection severity, infection had no effect on any of the variables assessed in at-risk drinkers. Post-hoc comparisons showed that B-lymphocyte, noncytotoxic, and cytotoxic T lymphocyte and CD16^– counts in at-risk drinkers were similar to those in not-at-risk drinkers with infection and significantly lower than those in not-at-risk drinkers without infection. Neutrophil CD64 index varied significantly between groups, with variations related to infection, not previous alcohol consumption.

Conclusions

These results show that chronic alcohol exposure has an impact on the immune response to infection in critically ill medical patients. The absence of significant variations in circulating WBC seen in at-risk drinkers according to the severity of infection is suggestive of altered immune response.

[Acute respiratory distress syndrome related to intra-alveolar hemorrhage revealing a vasculitis]

Intra-alveolar hemorrhage (IAH) could be revealed by acute respiratory failure. The classic association of hemoptysis - anemia - radiological infiltrates is suggestive and has to be confirmed by broncho-alveolar lavage with Golde score. Etiologies included immune and non-immune diseases, with specific treatment for each. We report a case of IAH revealed by acute respiratory distress syndrome and anemia (3 g/dL), related to pulmonary and cerebral vasculitis without renal involvement. The patient was efficiently treated with corticosteroids and cyclophosphamide. This case highlights the critical role of BAL cytological analysis with Golde score, and the need for a rapid and accurate diagnosis in order to guide specific treatment. If histology is needed, renal biopsy even without renal involvement, or surgical lung biopsy is possible.

Toward new insights on the white blood cell differential by flow cytometry: a proof of concept study on the sepsis model

BACKGROUND

We sought to evaluate, on a model of sepsis, the clinical relevance of new parameters obtained on a white blood cell (WBC) differential by flow cytometry, implemented in the routine workflow of our hematology laboratory.

METHODS

A WBC with differential by flow cytometry was done on 459 patients at admission in intensive care unit. They were retrospectively categorized in having (i) infection or not or (ii) a high gravity score (severe sepsis or septic shock) or not. We analyzed by hierarchical clustering, in a multidimensional manner, 50 parameters provided by the flow cytometric platform in place of the standard seven parameters for a standard differential.

RESULTS

Our approach allows to discriminate on the basis of a WBC differential (i) infected patients at admission based on a 16 parameter signature, with a concordance rate of 72.7% and a specificity of 79.9% and (ii) patients with high gravity score (septic shock or severe sepsis) at admission with a signature of eight parameters, with a concordance rate of 74.7% and a specificity of 75.9%.

CONCLUSIONS

This study shows the clinical relevance of an extended WBC differential to obtain by a flow cytometer integrated into a routine hematology laboratory workflow. Development of such approach implicates the redefinition of the WBC differential by integrating new parameters.

Electrical impedance tomography compared to positron emission tomography for the measurement of regional lung ventilation: an experimental study

Introduction

Electrical impedance tomography (EIT), which can assess regional lung ventilation at the bedside, has never been compared with positron-emission tomography (PET), a gold-standard to quantify regional ventilation. This experiment systematically compared both techniques in injured and non-injured lungs.

Methods

The study was performed in six mechanically ventilated female piglets. In normal lungs, tidal volume (V_T) was randomly changed to 6, 8, 10 and 15 ml/kg on zero end-expiratory pressure (ZEEP), then, at V_T 10 ml/kg, positive end-expiratory pressure (PEEP) was randomly changed to 5, 10 and 15 cmH₂O. Afterwards, acute lung injury (ALI) was subsequently created in three animals by injecting 3 ml/kg hydrochloric acid into the trachea. Then at PEEP 5 cmH₂O, V_T was randomly changed to 8 and 12 ml/kg and PEEP of 10 and 15 cmH₂O applied at V_T 10 ml/kg. EIT and PET examinations were performed simultaneously. EIT ventilation (V_TEIT) and lung volume (V_L) were measured in the anterior and posterior area of each lung. On the same regions of interest, ventilation (V_PET) and aerated lung volume (VA_atten) were determined with PET.

Results

On ZEEP, V_TEIT and V_PET significantly correlated for global (V_TEIT = VPET - 2E-13, R² = 0.95, P < 0.001) and regional (V_TEIT = 0.81V_PET+7.65, R² = 0.63, P < 0.001) ventilation over both conditions. For ALI condition, corresponding R² were 0.91 and 0.73 (P < 0.01). Bias was = 0 and limits of agreement were -37.42 and +37.42 ml/min for global ventilation over both conditions. These values were 0.04 and -29.01 and +29.08 ml/min, respectively, for regional ventilation. Significant correlations were also found between V_L and VA_atten for global (V_L = VA_atten+1E-12, R² = 0.93, P < 0.0001) and regional (V_L = 0.99VA_atten+0.92, R² = 0.65, P < 0.001) volume. For ALI condition, corresponding R² were 0.94 (P < 0.001) and 0.54 (P < 0.05). Bias was = 0 and limits of agreement ranged -38.16 and +38.16 ml for global ventilation over both conditions. These values were -0.24 and -31.96 to +31.48 ml, respectively, for regional ventilation.

Conclusions

Regional lung ventilation and volume were accurately measured with EIT in healthy and injured lungs and validated by simultaneous PET imaging.

Syncytia formation affects the yield and cytotoxicity of an adenovirus expressing a fusogenic glycoprotein at a late stage of replication

Fusogenic membrane glycoproteins (FMGs) may enhance the cytotoxicity of conditionally replicative adenoviruses. However, expression at early stages of infection impairs virus replication. We have inserted the hyperfusogenic form of the gibbon ape leukemia virus (GALV) envelope glycoprotein as a new splice unit of the major late promoter (MLP) to generate a replication-competent adenovirus expressing this protein. At high multiplicity of infection (MOI), this virus replicated efficiently forming clumps of fused cells and showing a faster release. In contrast, at low MOI, infected cells formed syncytia where only one nucleus contained virus DNA, decreasing total virus production but increasing cytotoxicity.

Diagnosis of early coagulation abnormalities in trauma patients by rotation thrombelastography

BACKGROUND

Reagent-supported thromboelastometry with the rotation thrombelastography (e.g. ROTEM) is a whole blood assay that evaluates the visco-elastic properties during blood clot formation and clot lysis. A hemostatic monitor capable of rapid and accurate detection of clinical coagulopathy within the resuscitation room could improve management of bleeding after trauma.

OBJECTIVES

The goals of this study were to establish whether ROTEM correlated with standard coagulation parameters to rapidly detect bleeding disorders and whether it can help to guide transfusion.

METHODS

Ninety trauma patients were included in the study. At admission, standard coagulation assays were performed and ROTEM parameters such as clot formation time (CFT) and clot amplitude (CA) were obtained at 15 min (CA(15)) with two activated tests (INTEM, EXTEM) and at 10 min (CA(10)) with a test analyzing specifically the fibrin component of coagulation (FIBTEM).

RESULTS

Trauma induced significant modifications of coagulation as assessed by standard assays and ROTEM. A significant correlation was found between prothrombin time (PT) and CA(15)-EXTEM (r = 0.66, P < 0.0001), between activated partial thromboplastin time and CFT-INTEM (r = 0.91, P < 0.0001), between fibrinogen level and CA(10)-FIBTEM (r = 0.85, P < 0.0001), and between platelet count and CA(15)-INTEM (r = 0.57, P < 0.0001). A cutoff value of CA(15)-EXTEM at 32 mm and CA(10)-FIBTEM at 5 mm presented a good sensitivity (87% and 91%) and specificity (100% and 85%) to detect a PT > 1.5 of control value and a fibrinogen less than 1 g L(-1), respectively.

CONCLUSIONS

ROTEM is a point-of-care device that rapidly detects systemic changes of in vivo coagulation in trauma patients, and it might be a helpful device in guiding transfusion.

Otoacoustic emissions and auditory assessment in infants at risk for early brain damage

The importance of early hearing screening has long been recognized, as the prognosis for the hearing impaired child is improved when the diagnosis is made as early as possible, and the intervention is begun immediately. For clinical screening of hearing impairment, the recording of otoacoustic emissions was recommended. As some risk factors for early brain damage are at the same time also risk factors for dysfunction of auditory system, we presumed that infants at risk for brain damage have hearing impairment more frequently than the rest of the population of the same age. We were interested in the role of otoacoustic emission testing during the assessment of auditory function in these infants. There were 110 infants at risk for brain damage included in the study. After thorough otorhinolaryngological examination, auditory function was estimated by recording of otoacoustic emissions, tympanometry, pure tone audiometry and, when necessary, auditory brainstem responses. Otoacoustic emissions were recorded by Madsen-Electronics Celesta 503 in an acoustically treated sound room. We registered spontaneous as well as transient and distortion product otoacoustic emissions. The neurologist formed two groups with different degrees of neurological risk. The collected results of auditory function were compared with the degree of neurological risk. For the statistical analysis, the procedure chi(2) and Fischer test were used. Spontaneous otoacoustic emission was detected in 38.2% of examinees. Evoked otoacoustic emissions were registered in 87.3% of infants. The testing had to be repeated in 32.7% of infants. We observed evoked otoacoustic emissions to be present also in a child with sensorineural hearing impairment and no auditory brainstem responses. Up to 32.7% of infants at risk for brain damage were hard of hearing. Conductive hearing loss was discovered with 25.4% of infants, and eight (7.3%) had sensorineural hearing impairment. In the group of examinees with only risk factors 3.6% had sensorineural impairment and in a group with abnormal motor development, there were 18.5% with that kind of hearing loss. Fischer test confirmed a statistically significant difference between the groups. Infants at risk for brain damage have more frequently impaired auditory function than their peers. For this reason, it is especially important to focus attention on the hearing condition when dealing with this population. Recording of evoked otoacoustic emissions is very helpful in pediatric audiometry, but any interpretation of the results should consider the possibility of auditory neuropathy.

Does it make sense to preserve the stapedial muscle during surgical treatment for otosclerosis?

Our study aimed to show whether it is useful to preserve the stapedial muscle during the surgical treatment of otosclerosis. The study was carried out on 67 patients with tympanoscopic evidence of otosclerosis. In group A (34 patients) the stapedial muscle was intra-operatively preserved as follows: the stapedial suprastructure with preserved muscle tendon was transpositioned onto the longer arm of the incus and secured with a wire loop. The mean uncomfortable level for sounds was measured after surgery and the results of group A patients were compared with those obtained in group B (33 patients, who underwent standard surgery). One month after surgery, in group A patients, the cochleostapedial reflex was evoked in 21 patients (61.8 per cent) and two months later in 32 patients (94.1 per cent). One month after operation, in group A patients the mean uncomfortable level was 108.8 dB, while three months later it increased to 114.1 dB. In group B, the relevant values were 97.8 dB one month after surgery, and 98.0 dB three months later. Our presumption that stapedial muscle preservation is necessary has been proved by the fact that the patients with the preserved muscle had a higher noise discomfort threshold.