Neuroimmune activation is associated with neurological outcome in anoxic and traumatic coma.

The pathophysiological underpinnings of critically disrupted brain connectomes resulting in coma are poorly understood. Inflammation is potentially an important but still undervalued factor. Here, we present a first-in-human prospective study using the 18-kDa translocator protein (TSPO) radioligand 18F-DPA714 for PET imaging to allow in vivo neuroimmune activation quantification in patients with coma (n = 17) following either anoxia or traumatic brain injuries in comparison with age- and sex-matched controls. Our findings yielded novel evidence of an early inflammatory component predominantly located within key cortical and subcortical brain structures that are putatively implicated in consciousness emergence and maintenance after severe brain injury (i.e. mesocircuit and frontoparietal networks). We observed that traumatic and anoxic patients with coma have distinct neuroimmune activation profiles, both in terms of intensity and spatial distribution. Finally, we demonstrated that both the total amount and specific distribution of PET-measurable neuroinflammation within the brain mesocircuit were associated with the patient's recovery potential. We suggest that our results can be developed for use both as a new neuroprognostication tool and as a promising biometric to guide future clinical trials targeting glial activity very early after severe brain injury.

Accuracy of pulse pressure variations for fluid responsiveness prediction in mechanically ventilated patients with biphasic positive airway pressure mode.

The accuracy of pulse pressure variation (PPV) to predict fluid responsiveness using pressure-controlled (PC) instead of volume-controlled modes is under debate. To specifically address this issue, we designed a study to evaluate the accuracy of PPV to predict fluid responsiveness in severe septic patients who were mechanically ventilated with biphasic positive airway pressure (BIPAP) PC-ventilation mode. 45 patients with sepsis or septic shock and who were mechanically ventilated with BIPAP mode and a target tidal volume of 7-8 ml/kg were included. PPV was automatically assessed at baseline and after a standard fluid challenge (Ringer's lactate 500 ml). A 15% increase in stroke volume (SV) defined fluid responsiveness. The predictive value of PPV was evaluated through a receiver operating characteristic (ROC) curve analysis and "gray zone" statistical approach. 20 (44%) patients were considered fluid responders. We identified a significant relationship between PPV decrease after volume expansion and SV increase (spearman ρ = - 0.5, p < 0.001). The area under ROC curve for PPV was 0.71 (95%CI 0.56-0.87, p = 0.007). The best cut-off (based on Youden's index) was 8%, with a sensitivity of 80% and specificity of 60%. Using a gray zone approach, we identified that PPV values comprised between 5 and 15% do not allow a reliable fluid responsiveness prediction. In critically ill septic patients ventilated under BIPAP mode, PPV appears to be an accurate method for fluid responsiveness prediction. However, PPV values comprised between 5 and 15% constitute a gray zone that does not allow a reliable fluid responsiveness prediction.

Machine learning methods to improve bedside fluid responsiveness prediction in severe sepsis or septic shock: an observational study.

BACKGROUND: Passive leg raising (PLR) predicts fluid responsiveness in critical illness, although restrictions in mobilising patients often preclude this haemodynamic challenge being used. We investigated whether machine learning applied on transthoracic echocardiography (TTE) data might be used as a tool for predicting fluid responsiveness in critically ill patients. METHODS: We studied, 100 critically ill patients (mean age: 62 yr [standard deviation: 14]) with severe sepsis or septic shock prospectively over 24 months. Transthoracic echocardiography measurements were performed at baseline, after PLR, and before and after a standardised fluid challenge in learning and test populations (n=50 patients each). A 15% increase in stroke volume defined fluid responsiveness. The machine learning methods used were classification and regression tree (CART), partial least-squares regression (PLS), neural network (NNET), and linear discriminant analysis (LDA). Each method was applied offline to determine whether fluid responsiveness may be predicted from left and right cardiac ventricular physiological changes detected by cardiac ultrasound. Predictive values for fluid responsiveness were compared by receiver operating characteristics (area under the curve [AUC]; mean [95% confidence intervals]). RESULTS: In the learning sample, the AUC values were PLR 0.76 (0.62-0.89), CART 0.83 (0.73-0.94), PLS 0.97 (0.93-1), NNET 0.93 (0.85-1), and LDA 0.90 (0.81-0.98). In the test sample, the AUC values were PLR 0.77 (0.64-0.91), CART 0.68 (0.54-0.81), PLS 0.83 (0.71-0.96), NNET 0.83 (0.71-0.94), and LDA 0.85 (0.74-0.96) respectively. The PLS model identified inferior vena cava collapsibility, velocity-time integral, S-wave, E/Ea ratio, and E-wave as key echocardiographic parameters. CONCLUSIONS: Machine learning generated several models for predicting fluid responsiveness that were comparable with the haemodynamic response to PLR.

How Should we Use Multicolumn Spinal Cord Stimulation to Optimize Back Pain Spatial Neural Targeting? A Prospective, Multicenter, Randomized, Double-Blind, Controlled Trial (ESTIMET Study).

BACKGROUND: Recent studies have highlighted multicolumn spinal cord stimulation (SCS) efficacy, hypothesizing that optimized spatial neural targeting provided by new-generation SCS lead design or its multicolumn programming abilities could represent an opportunity to better address chronic back pain (BP). OBJECTIVE: To compare multicolumn vs. monocolumn programming on clinical outcomes of refractory postoperative chronic BP patients implanted with SCS using multicolumn surgical lead. MATERIALS AND METHODS: Twelve centers included 115 patients in a multicenter, randomized, double-blind, controlled trial. After randomization, leads were programmed using only one or several columns. The primary outcome was change in BP visual analogic scale (VAS) at six months. All patients were then programmed using the full potential of the lead up until 12-months follow-up. RESULTS: At six months, there was no significant difference in clinical outcomes whether the SCS was programmed using a mono or a multicolumn program. At 12 months, in all patients having been receiving multicolumn SCS for at least six months (n = 97), VAS decreases were significant for global pain (45.1%), leg pain (55.8%), and BP (41.5%) compared with baseline (p < 0.0001). CONCLUSION: The ESTIMET study confirms the significant benefit experienced on chronic BP by patients implanted with multicolumn SCS, independently from multicolumn lead programming. These good clinical outcomes might result from the specific architecture of the multicolumn lead, giving the opportunity to select initially the best column on a multicolumn grid and to optimize neural targeting with low-energy requirements. However, involving more columns than one does not appear necessary, once initial spatial targeting of the "sweet spot" has been achieved. Our findings suggest that this spatial concept could also be transposed to cylindrical leads, which have drastically improved their capability to shape the electrical field, and might be combined with temporal resolution using SCS new modalities.

Outcomes of pre-operative brachytherapy followed by hysterectomy for early cervical cancer.

OBJECTIVE: The standard of care for early cervical cancer is radical hysterectomy; however, consideration of pre-operative brachytherapy has been explored. We report our experience using pre-operative brachytherapy plus Wertheim-type hysterectomy to treat early stage cervical cancer. METHODS: This single-center study evaluated consecutive patients with histologically proven node-negative early stage cervical cancer (International Federation of Gynecology and Obstetrics 2009 stage IB1-IIB) that was treated using pre-operative brachytherapy and hysterectomy. Pre-brachytherapy staging was performed using magnetic resonance imaging (MRI) and pelvic lymph node assessment was performed using lymphadenectomy. The tumor and cervical tissues were treated using brachytherapy (total dose 60 Gy) followed by Wertheim-type hysterectomy. The study included patients from January 2000 to December 2013. RESULTS: A total of 80 patients completed a median follow-up of 6.7 years (range 5.4-8.5). The surgical specimens revealed a pathological complete response for 61 patients (76%). Patients with incomplete responses generally had less than 1 cm residual tumor at the cervix, and only one patient had lymphovascular space involvement. The estimated 5-year rates were 88% for overall survival (95% CI 78% to 94%) and 82% for disease-free survival (95% CI 71% to 89%). Toxicities were generally mild-to-moderate, including 26 cases (33%) of grade 2 late toxicity and 10 cases (13%) of grade 3 late toxicity. Univariate analyses revealed that poor disease-free survival was associated with overweight status (≥25 kg/m2, HR 3.05, 95% CI 1.20 to 7.76, p=0.019) and MRI tumor size >3 cm (HR 3.05, 95% CI 1.23 to 7.51, p=0.016). CONCLUSIONS: Pre-operative brachytherapy followed by Wertheim-type hysterectomy may be safe and effective for early stage cervical cancer, although poorer outcomes were associated with overweight status and MRI tumor size >3 cm.

Diaphragmatic paralysis in obese patients in arthroscopic shoulder surgery: consequences and causes.

PURPOSE: Ambulatory process in arthroscopic shoulder surgery has boomed over past decades. Some anesthetic techniques such as interscalene block (ISB) and its surrogates are associated with diaphragmatic paralysis and might compromise outpatient procedure. HYPOTHESIS: This study aims to assess consequences of diaphragmatic paralysis in obese patients. METHODS: This prospective observational study screened patients with body mass index (BMI) ≥ 30 kg/m2 undergoing acromioplasty or supraspinatus tendon repair. Surgery was performed using brachial plexus block, and the method of brachial plexus block was left at the discretion of attending anesthesiologists. Post-operative hemidiaphragmatic paralysis was evaluated using M-mode ultrasonography and its consequences on patient ventilation were assessed: occurrence of hypoxic episode defined as oxygen saturation less than 90% (by pulse oximeter) in room air, dyspnea and failure of ambulatory procedure. Causes of diaphragmatic paralysis were also analyzed. RESULTS: Ninety-one patients were screened, 82 patients were included in this study and 37 patients (45%) presented diaphragmatic paralysis. Compared to patients without diaphragmatic paralysis, diaphragmatic paralysis was associated with dyspnea [10 (27%) versus 1 (2%); p = 0.0019], occurrence of patients presenting at least one hypoxic episode [6 (16%) versus 1 (2%); p = 0.02] and failure of ambulatory process [10 (27%) versus 1 (2%); p = 0.009]. The combination of axillary and suprascapular nerve blocks, but also low volume ISB, was found to be protective against diaphragmatic paralysis when compared to high volume ISB [Odds ratios 0.0019 (0.001-0.026) and 0.0482 (0.008-0.27), respectively; p < 0.001]. CONCLUSION: In patients with BMI ≥ 30 kg/m2 undergoing arthroscopic shoulder surgery, diaphragmatic paralysis is associated with dyspnea, occurrence of hypoxic episodes and failure of ambulatory procedure. High volume ISB and also, to a lesser extent, low volume ISB were found to be responsible for diaphragmatic paralysis. TRIAL REGISTRY NUMBER: Registration n° 2014-202.

Brain Gray Matter MRI Morphometry for Neuroprognostication After Cardiac Arrest.

OBJECTIVES: We hypothesize that the combined use of MRI cortical thickness measurement and subcortical gray matter volumetry could provide an early and accurate in vivo assessment of the structural impact of cardiac arrest and therefore could be used for long-term neuroprognostication in this setting. DESIGN: Prospective cohort study. SETTING: Five Intensive Critical Care Units affiliated to the University in Toulouse (France), Paris (France), Clermont-Ferrand (France), Liège (Belgium), and Monza (Italy). PATIENTS: High-resolution anatomical T1-weighted images were acquired in 126 anoxic coma patients ("learning" sample) 16 ± 8 days after cardiac arrest and 70 matched controls. An additional sample of 18 anoxic coma patients, recruited in Toulouse, was used to test predictive model generalization ("test" sample). All patients were followed up 1 year after cardiac arrest. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Cortical thickness was computed on the whole cortical ribbon, and deep gray matter volumetry was performed after automatic segmentation. Brain morphometric data were employed to create multivariate predictive models using learning machine techniques. Patients displayed significantly extensive cortical and subcortical brain volumes atrophy compared with controls. The accuracy of a predictive classifier, encompassing cortical and subcortical components, has a significant discriminative power (learning area under the curve = 0.87; test area under the curve = 0.96). The anatomical regions which volume changes were significantly related to patient's outcome were frontal cortex, posterior cingulate cortex, thalamus, putamen, pallidum, caudate, hippocampus, and brain stem. CONCLUSIONS: These findings are consistent with the hypothesis of pathologic disruption of a striatopallidal-thalamo-cortical mesocircuit induced by cardiac arrest and pave the way for the use of combined brain quantitative morphometry in this setting.

Combined Thoracic Ultrasound Assessment during a Successful Weaning Trial Predicts Postextubation Distress.

BACKGROUND: Recent studies suggest that isolated sonographic assessment of the respiratory, cardiac, or neuromuscular functions in mechanically ventilated patients may assist in identifying patients at risk of postextubation distress. The aim of the present study was to prospectively investigate the value of an integrated thoracic ultrasound evaluation, encompassing bedside respiratory, cardiac, and diaphragm sonographic data in predicting postextubation distress. METHODS: Longitudinal ultrasound data from 136 patients who were extubated after passing a trial of pressure support ventilation were measured immediately after the start and at the end of this trial. In case of postextubation distress (31 of 136 patients), an additional combined ultrasound assessment was performed while the patient was still in acute respiratory failure. We applied machine-learning methods to improve the accuracy of the related predictive assessments. RESULTS: Overall, integrated thoracic ultrasound models accurately predict postextubation distress when applied to thoracic ultrasound data immediately recorded before the start and at the end of the trial of pressure support ventilation (learning sample area under the curve: start, 0.921; end, 0.951; test sample area under the curve: start, 0.972; end, 0.920). Among integrated thoracic ultrasound data, the recognition of lung interstitial edema and the increased telediastolic left ventricular pressure were the most relevant predictive factors. In addition, the use of thoracic ultrasound appeared to be highly accurate in identifying the causes of postextubation distress. CONCLUSIONS: The decision to attempt extubation could be significantly assisted by an integrative, dynamic, and fully bedside ultrasonographic assessment of cardiac, lung, and diaphragm functions.

Ultrasound-guided bilateral stellate ganglion blockade to treat digital ischemia in a patient with sepsis: a case report.

PURPOSE: This case report describes the use of ultrasound-guided stellate ganglion blockade to treat sepsis-related digital ischemia in the intensive care unit (ICU). CLINICAL FEATURES: A 71-yr-old female was admitted to the ICU with septic shock and acute respiratory distress syndrome (ARDS) following an initial right hemicolectomy complicated by an anastomotic leak and peritonitis. The patient's condition was further complicated by an abdominal abscess 22 days later. She had type-2 diabetes mellitus and hypertension but no history of vascular disease. With continuing sepsis from the abscess and requiring mechanical ventilation due to ARDS, she developed upper limb digital ischemia refractory to treatment with a low dose of dobutamine and isosorbide dinitrate. We subsequently performed ultrasound-guided bilateral stellate ganglion blockade with the intent of restoring perfusion to her fingers before digital necrosis developed. One hour after each stellate ganglion block, the symptoms of digital ischemia completely resolved. The benefit persisted for two days, and then a repeat block was performed with similar results. CONCLUSIONS: This case illustrates the potential advantages of ultrasound-guided stellate ganglion blockade for the treatment of sepsis-related digital ischemia refractory to standard therapy.

Designing an operating theatre for awake procedures: A solution to improve multimodality information input.

OBJECTIVE: Many neurosurgical procedures are now performed with the patient aware in order to allow interactions between the patient and healthcare professionals. These procedures include awake brain surgery and spinal cord stimulation (SCS), lead placement for treatment of refractory chronic back and leg pain. Neurosurgical procedures under local anaesthesia require optimal intraoperative cooperation of the patient and all personnel involved in surgery. In addition to accommodating this extra source of intraoperative information all other necessary sources of data relevant to the procedure must be presented. The concept of an operating room dedicated to neurosurgical procedures performed aware and accommodating these concepts is presented, and some evidence for improvements in outcome presented, deriving from a series of patients implanted with spinal cord stimulators before and after the operating theatre was brought into service. RESULTS AND DISCUSSION: In addition to the description, two videos demonstrate the facility online. Beyond this qualitative evidence, quantitative improvement in patient outcome is evidenced by the series presented: 91.3% of patients operated in the awake anaesthesia-dedicated theatre obtained adequate low back pain coverage, versus 60.0% for patients operated before (p = 0.028). CONCLUSION: The concept of such an operating room is a step in improving the outcome by improving the presentation of all types of information to the operating room staff most notably in the example of aware procedures.

Accuracy of ultrasound B-lines score and E/Ea ratio to estimate extravascular lung water and its variations in patients with acute respiratory distress syndrome.

Extravascular lung water (EVLW) could increase by permeability pulmonary oedema, cardiogenic oedema, or both. Transthoracic echocardiography examination of a patient allows quantifying B-lines, originating from water-thickened interlobular septa, and the E/Ea ratio, related to pulmonary capillary wedge pressure. The aim of our study was to assess the correlation and the trending ability between EVLW measured by transpulmonary thermodilution and the B-lines score or the E/Ea ratio in patients with ARDS. Twenty-six intensive care unit patients were prospectively included. B-lines score was obtained from four ultrasound zones (anterior and lateral chest on left and right hemithorax). E/Ea was measured from the apical four-chamber view. EVLW was compared with the B-lines score and the E/Ea ratio. A linear mixed effect model was used to take account the repeated measurements. A p value<0.05 was considered significant. A total of 73 measurements were collected. The correlation coefficient between EVLW and B-lines score was 0.66 (EVLW=0.71 B-lines+7.64, R2=0.44, p=0.001), versus 0.31 for E/Ea (p=0.06). The correlation between EVLW changes and B-lines variations was significant (R2=0.26, p<0.01), with a concordance rate of 74%. A B-lines score≥6 had a sensitivity of 82% and a specificity of 77% to predict EVLW>10 ml/kg, with an AUC equal to 0.86 (0.76-0.93). The gray zone approach identified a range of B-lines between four and seven for which EVLW>10 ml/kg could not be predicted reliably. The correlation between ultrasound B-lines and EVLW was significant, but the B-lines score was not able to track EVLW changes reliably.

An algorithmic programming approach for back pain symptoms in failed back surgery syndrome using spinal cord stimulation with a multicolumn surgically implanted epidural lead: a multicenter international prospective study.

INTRODUCTION: Many studies have demonstrated the efficacy and the medical/economic value of epidural spinal cord stimulation for the treatment of "failed back surgery syndrome" (FBSS). However, the back pain component of FBSS has been recalcitrant. Recent clinical trials have suggested that multicolumn surgically implanted leads combined with enhanced programming capabilities in the newer implantable pulse generators demonstrate the ability to treat the back pain component of FBSS. The objective of our present international multicentre study is to prospectively evaluate these findings in a larger population. METHODS: We conducted a prospective, nonrandomized, observational study on 76 patients with refractory FBSS, consecutively implanted with multicolumn spinal cord stimulation (SCS) between 2008 and 2011 in three neurosurgical pain management centers (Poitiers, France; Montréal, Canada; and Regina, Canada). The primary objective of this study was to prospectively analyze the effect of multicolumn lead programming on paresthesia coverage for the back pain region in these patients. The secondary objective was to assess the analgesic efficacy of this technique on the global and back pain components. RESULTS: Paresthesia could be induced in the lower extremities in the majority of patients with at least one of the configurations tested. Bilateral low back paresthesia was induced in 53.5% of patients, while unilateral low back paresthesia was induced in 78.9% of patients. Multicolumn configurations were statistically more effective than monocolumn configurations for all anatomic regions studied. At 6 months, 75.4% of patients receiving multicolumn stimulation (n = 57) obtained at least a 30% improvement of the back pain VAS score, while 42.1% of patients obtained at least a 50% improvement of the back pain VAS score. CONCLUSION: This study confirms the hypothesis that multicolumn SCS should be considered as an important tool in the treatment of radicular and axial pain in FBSS patients. The efficacy of this modality is based on a rigorous patient selection process, access to new generation lead technologies, but most importantly an algorithmic programming approach for optimal stimulation and electrical field shaping. With over 40 million potential programming combinations associated with 16 contact leads to achieve paresthesia coverage, optimal stimulation is often missed as either the patient or the clinician become exhausted or overwhelmed during the course of therapy programming and optimization session.

Neuronal activity correlated with checking behaviour in the subthalamic nucleus of patients with obsessive-compulsive disorder.

Doubt, and its behavioural correlate, checking, is a normal phenomenon of human cognition that is dramatically exacerbated in obsessive-compulsive disorder. We recently showed that deep brain stimulation in the associative-limbic area of the subthalamic nucleus, a central core of the basal ganglia, improved obsessive-compulsive disorder. To understand the physiological bases of symptoms in such patients, we recorded the activity of individual neurons in the therapeutic target during surgery while subjects performed a cognitive task that gave them the possibility of unrestricted repetitive checking after they had made a choice. We postulated that the activity of neurons in this region could be influenced by doubt and checking behaviour. Among the 63/87 task-related neurons recorded in 10 patients, 60% responded to various combinations of instructions, delay, movement or feedback, thus highlighting their role in the integration of different types of information. In addition, task-related activity directed towards decision-making increased during trials with checking in comparison with those without checking. These results suggest that the associative-limbic subthalamic nucleus plays a role in doubt-related repetitive thoughts. Overall, our results not only provide new insight into the role of the subthalamic nucleus in human cognition but also support the fact that subthalamic nucleus modulation by deep brain stimulation reduced compulsive behaviour in patients with obsessive-compulsive disorder.

Evaluation of External Trigeminal Nerve Stimulation to Prevent Cerebral Vasospasm after Subarachnoid Hemorrhage Due to Aneurysmal Rupture: A Randomized, Double-Blind Proof-of-Concept Pilot Trial (TRIVASOSTIM Study).

Cerebral vasospasm remains the most frequent and devastating complication after subarachnoid aneurysmal hemorrhage because of secondary cerebral ischemia and its sequelae. The underlying pathophysiology involves vasodilator peptide release (such as CGRP) and nitric oxide depletion at the level of the precapillary sphincters of the cerebral (internal carotid artery network) and dural (external carotid artery network) arteries, which are both innervated by craniofacial autonomic afferents and tightly connected to the trigeminal nerve and trigemino-cervical nucleus complex. We hypothesized that trigeminal nerve modulation could influence the cerebral flow of this vascular network through a sympatholytic effect and decrease the occurrence of vasospasm and its consequences. We conducted a prospective double-blind, randomized controlled pilot trial to compare the effect of 10 days of transcutaneous electrical trigeminal nerve stimulation vs. sham stimulation on cerebral infarction occurrence at 3 months. Sixty patients treated for aneurysmal SAH (World Federation of Neurosurgical Societies scale between 1 and 4) were included. We compared the radiological incidence of delayed cerebral ischemia (DCI) on magnetic resonance imaging (MRI) at 3 months in moderate and severe vasospasm patients receiving trigeminal nerve stimulation (TNS group) vs. sham stimulation (sham group). Our primary endpoint (the infarction rate at the 3-month follow-up) did not significantly differ between the two groups (p = 0.99). Vasospasm-related infarctions were present in seven patients (23%) in the TNS group and eight patients (27%) in the sham group. Ultimately, we were not able to show that TNS can decrease the rate of cerebral infarction secondary to vasospasm occurrence. As a result, it would be premature to promote trigeminal system neurostimulation in this context. This concept should be the subject of further research.

Influence of Deep Serratus Anterior Plane Block on Chronic Pain at 3 Months After Breast-Conserving Surgery: Prospective, Cohort Study.

OBJECTIVES: In 2015, we evaluated our practices regarding pain after breast-conserving surgery. Thereafter, we have adapted our practices by performing a systematic deep serratus plane block before the surgical incision. In 2019, we assessed the impact of these changes in terms of chronic pain. The main objective of this study was to evaluate the prevalence of chronic pain 3 months after this type of surgery. MATERIALS AND METHODS: All patients treated with breast-conserving surgery as outpatients were included in this prospective study between April and July 2019. After inducing general anesthesia, 20 mL of ropivacaine 3.75 mg/mL were injected under the serratus muscle. Morphine titration was performed in the recovery room according to pain scores. A pain and quality of life questionnaire was sent 3 months after surgery. A backward logistic regression model was applied to calculate the adjusted odds ratios. RESULTS: The final analysis involved 137 patients. Three months after surgery, 43 patients (31%) reported persistent pain related to the surgery. Maximum pain in the last 24 hours was moderate to severe in 60% of cases, 16 patients (35%) took painkillers. Morphine titration in the recovery room was required in 25 patients (18%). Younger age and the use of lidocaine to prevent after injection of propofol during general anesthesia induction appeared to be protective factors for the risk of pain at 3 months (secondary endpoints). DISCUSSION: No persistent pain at 3 months was reported in 69% of cases. Furthermore, the use of a deep serratus anterior plane block before the surgical incision has limited the need for morphine titration in the recovery room to <1 patient in 5. These evaluations of professional practices should be encouraged.

Lung Ultrasound to Assist ICU Admission Decision-Making Process of COVID-19 Patients With Acute Respiratory Failure.

There is only low-certainty evidence on the use of predictive models to assist COVID-19 patient's ICU admission decision-making process. Accumulative evidence suggests that lung ultrasound (LUS) assessment of COVID-19 patients allows accurate bedside evaluation of lung integrity, with the added advantage of repeatability, absence of radiation exposure, reduced risk of virus dissemination, and low cost. Our goal is to assess the performance of a quantified indicator resulting from LUS data compared with standard clinical practice model to predict critical respiratory illness in the 24 hours following hospital admission. DESIGN: Prospective cohort study. SETTING: Critical Care Unit from University Hospital Purpan (Toulouse, France) between July 2020 and March 2021. PATIENTS: Adult patients for COVID-19 who were in acute respiratory failure (ARF), defined as blood oxygen saturation as measured by pulse oximetry less than 90% while breathing room air or respiratory rate greater than or equal to 30 breaths/min at hospital admission. Linear multivariate models were used to identify factors associated with critical respiratory illness, defined as death or mild/severe acute respiratory distress syndrome (Pao2/Fio2 < 200) in the 24 hours after patient's hospital admission. INTERVENTION: LUS assessment. MEASUREMENTS AND MAIN RESULTS: One hundred and forty COVID-19 patients with ARF were studied. This cohort was split into two independent groups: learning sample (first 70 patients) and validation sample (last 70 patients). Interstitial lung water, thickening of the pleural line, and alveolar consolidation detection were strongly associated with patient's outcome. The LUS model predicted more accurately patient's outcomes than the standard clinical practice model (DeLong test: Testing: z score = 2.50, p value = 0.01; Validation: z score = 2.11, p value = 0.03). CONCLUSIONS: LUS assessment of COVID-19 patients with ARF at hospital admission allows a more accurate prediction of the risk of critical respiratory illness than standard clinical practice. These results hold the promise of improving ICU resource allocation process, particularly in the case of massive influx of patients or limited resources, both now and in future anticipated pandemics.

Evaluation of the impact of the COVID-19 lockdown on the quality of life of patients monitored for cancer who practice an adapted physical activity: rugby for health.

PURPOSE: The benefits of regular physical exercise on the tolerability of cancer treatments, quality of life and survival rates post-diagnosis have been demonstrated but all supervised physical activities have been interrupted due to the global health crisis and the need for lockdown to halt the spread of SARS-CoV-2. To reintroduce activities post-lockdown, we wanted to assess the impact of the COVID-19 lockdown on the quality of life and the psychological status of patients who practice an adapted physical activity such as rugby for health. METHODS: The evaluation was conducted in two phases: an initial self-questionnaire comprised of 42 questions sent to all participants to assess the impact of lockdown and a second assessment phase in the presence of the participants. We assessed anthropometric data, functional fitness parameters, quality of life and the psychosocial status of the subjects. The data were compared to pre-lockdown data as part of a standardised follow-up procedure for patients enrolled in the programme. RESULTS: 105/120 (87.5%) individuals responded to the rapid post-lockdown survey analysis. In 20% of the cases, the patients reported anxiety, pain, a decline in fitness and a significant impact on the tolerability of cancer treatments. Twenty-seven patients agreed to participate in the individual analysis. Following lockdown, there was a significant decrease in the intensity of physical activity (p = 8.223e-05). No post-lockdown changes were noted in the assessments that focus on the quality of life and the level of psychological distress. Conversely, there was a significant correlation between the total of high energy expended during lockdown and the quality of life (p = 0.03; rho = 0.2248) and the level of psychological distress post-lockdown (p = 0.05; rho = - 0.3772). CONCLUSION: Lockdown and reduced physical activity, particularly leisure activities, did not impact the overall health of the patients. However, there was a significant correlation with the level of physical activity since the higher the level of physical activity, the better the quality of life and the lower the level of psychological distress.

Subthalamic nucleus stimulation in severe obsessive-compulsive disorder.

BACKGROUND: Severe, refractory obsessive-compulsive disorder (OCD) is a disabling condition. Stimulation of the subthalamic nucleus, a procedure that is already validated for the treatment of movement disorders, has been proposed as a therapeutic option. METHODS: In this 10-month, crossover, double-blind, multicenter study assessing the efficacy and safety of stimulation of the subthalamic nucleus, we randomly assigned eight patients with highly refractory OCD to undergo active stimulation of the subthalamic nucleus followed by sham stimulation and eight to undergo sham stimulation followed by active stimulation. The primary outcome measure was the severity of OCD, as assessed by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), at the end of two 3-month periods. General psychopathologic findings, functioning, and tolerance were assessed with the use of standardized psychiatric scales, the Global Assessment of Functioning (GAF) scale, and neuropsychological tests. RESULTS: After active stimulation of the subthalamic nucleus, the Y-BOCS score (on a scale from 0 to 40, with lower scores indicating less severe symptoms) was significantly lower than the score after sham stimulation (mean [+/-SD], 19+/-8 vs. 28+/-7; P=0.01), and the GAF score (on a scale from 1 to 90, with higher scores indicating higher levels of functioning) was significantly higher (56+/-14 vs. 43+/-8, P=0.005). The ratings of neuropsychological measures, depression, and anxiety were not modified by stimulation. There were 15 serious adverse events overall, including 1 intracerebral hemorrhage and 2 infections; there were also 23 nonserious adverse events. CONCLUSIONS: These preliminary findings suggest that stimulation of the subthalamic nucleus may reduce the symptoms of severe forms of OCD but is associated with a substantial risk of serious adverse events. (ClinicalTrials.gov number, NCT00169377.)

Salvage Radiotherapy for Macroscopic Local Recurrence Following Radical Prostatectomy.

INTRODUCTION: Salvage radiotherapy is the only curative treatment for biochemical progression after radical prostatectomy. Macroscopic recurrence may be found in the prostatic bed. The purpose of our study is to evaluate the effectiveness of salvage radiotherapy of the prostate bed with a boost to the area of the macroscopic recurrence. MATERIAL AND METHODS: From January 2005 to January 2020, 89 patients with macroscopic recurrence in the prostatectomy bed were treated with salvage radiotherapy +/- hormone therapy. The average PSA level prior to radiotherapy was 1.1 ng/mL (SD: 1.6). At the time of biochemical progression, 96% of the patients had a MRI that revealed the macroscopic recurrence, and 58% had an additional choline PET scan. 67.4% of the patients got a boost to the macroscopic nodule, while 32.5% of the patients only underwent radiotherapy of the prostate bed without a boost. The median total dose of radiotherapy was 70 Gy (Min.: 60 - Max.: 74). The most commonly-used regimen was radiotherapy of the prostatectomy bed with a concomitant boost. 48% of the patients were concomitantly treated with hormone therapy. RESULTS: After a median follow-up of 53.7 months, 77 patients were alive and 12 had died, of which 4 following metastatic progression. The 5-year and 8-year survival rates (CI95%) are, respectively, 90.2% (78.9-95.6%) and 69.8% (46.4-84.4%). The 5-year biochemical progression-free survival rate (CI95%) is 50.8% (36.7-63.3). Metastatic recurrence occurred in 11.2% of the patients. We did not find any statistically significant impact from the various known prognostic factors for biochemical progression-free survival. No toxicity with a grade of > or = to 3 was found. CONCLUSIONS: Our series is one of the largest published to date. Salvage radiotherapy has its place in the management of patients with biochemical progression with local recurrence in the prostate bed, with an acceptable toxicity profile. The interest of the boost is to be evaluated in prospective trials.

Total knee arthroplasty under quadruple nerve block with ropivacaine 0.32%: effect of addition of intravenous dexmedetomidine to intravenous dexamethasone on analgesic duration.

BACKGROUND AND OBJECTIVES: Peripheral nerve blocks reduce postoperative pain and enhance recovery after total knee arthroplasty (TKA). This study aims to assess the benefits of addition of intravenous dexmedetomidine (DexM) to intravenous dexamethasone on the analgesic duration of quadruple nerve blocks. METHODS: This double-blind, randomized, controlled trial prospectively enrolled 90 patients scheduled for TKA under quadruple nerve blocks (sciatic, femoral, obturator, and lateral femoral cutaneous nerves blocks) with 70 mL, 0.32% ropivacaine. All patients received systemic dexamethasone 10 mg. Patients were randomized to receive DexM (2 µg/kg, intravenous) or placebo (1:1 ratio). The primary endpoint was the duration of analgesia defined as the time to first request for rescue analgesia (oxycodone). RESULTS: Kaplan-Meier curves for the first analgesic request were similar between groups (log-rank test; p=0.27). Median (IQR) duration of analgesia was similar between placebo (1575 min (1211-1952)) and DexM (1470 min (1263-1700)) groups (p=0.56). Cumulative consumption of oxycodone at the 48th hour was 20 mg (10-30) and 30 mg (20-40) in placebo and DexM groups, respectively (p=0.14). The day after surgery, 93% and 89% of patients were able to walk in placebo and DexM groups, respectively (p=0.46). Intravenous DexM was associated with bradycardia, hypotension and longer recovery room stay (p<0.05 for all comparisons). CONCLUSIONS: In a multimodal analgesic regimen, addition of systemic DexM (2 µg/kg) to systemic dexamethasone does not prolong the analgesic duration of quadruple nerve block with ropivacaine 0.32% after TKA. TRIAL REGISTRATION NUMBER: NCT03834129.