Low Percentage of Perforin-Expressing NK Cells during Severe SARS-CoV-2 Infection: Consumption Rather than Primary Deficiency.

Genetic defects in the ability to deliver effective perforin have been reported in patients with hemophagocytic lymphohistiocytosis. We tested the hypothesis that a primary perforin deficiency might also be causal in severe SARS-CoV-2 infection. We recruited 54 volunteers confirmed as being SARS-CoV-2-infected by RT-PCR and admitted to intensive care units or non-intensive care units and age- and sex-matched healthy controls. Compared with healthy controls, the percentage of perforin-expressing CD3-CD56+ NK cells quantified by flow cytometry was low in COVID-19 patients (69.9 ± 17.7 versus 78.6 ± 14.6%, p = 0.026). There was no correlation between the proportions of perforin-positive NK cells and T8 lymphocytes. Moreover, the frequency of NK cells producing perforin was neither linked to disease severity nor predictive of death. Although IL-6 is known to downregulate perforin production in NK cells, we did not find any link between perforin expression and IL-6 plasma level. However, we unveiled a negative correlation between the degranulation marker CD107a and perforin expression in NK cells (r = -0.488, p = 10-4). PRF1 gene expression and the frequency of NK cells harboring perforin were normal in patients 1 y after acute SARS-CoV-2 infection. A primary perforin defect does not seem to be a driver of COVID-19 because NK perforin expression is 1) linked neither to T8 perforin expression nor to disease severity, 2) inversely correlated with NK degranulation, and 3) normalized at distance from acute infection. Thus, the cause of low frequency of perforin-positive NK cells appears, rather, to be consumption.

Is the shock index correlated with blood loss? An experimental study on a controlled hemorrhagic shock model in piglets.

INTRODUCTION: The quantification of blood loss in a severe trauma patient allows prognostic quantification and the engagement of adapted therapeutic means. The Advanced Trauma Life Support classification of hemorrhagic shock, based in part on hemodynamic parameters, could be improved. The search for reproducible and non-invasive parameters closely correlated with blood depletion is a necessity. An experimental model of controlled hemorrhagic shock allowed us to obtain hemodynamic and echocardiographic measurements during controlled blood spoliation. The primary aim was to demonstrate the correlation between the Shock Index (SI) and blood depletion volume (BDV) during the hemorrhagic phase of an experimental model of controlled hemorrhagic shock in piglets. The secondary aim was to study the correlations between blood pressure (BP) values and BDV, SI and cardiac output (CO), and pulse pressure (PP) and stroke volume during the same phase. METHODS: We analyzed data from 66 anesthetized and ventilated piglets that underwent blood spoliation at 2 mL.kg-1.min-1 until a mean arterial pressure (MAP) of 40 mmHg was achieved. During this bleeding phase, hemodynamic and echocardiographic measurements were performed regularly. RESULTS: The correlation coefficient between the SI and BDV was 0.70 (CI 95%, [0.64; 0.75]; p < 0.01), whereas between MAP and BDV, the correlation coefficient was -0.47 (CI 95%, [-0.55; -0.38]; p < 0.01). Correlation coefficient between SI and CO and between PP and stroke volume were - 0.45 (CI 95%, [-0.53; -0.37], p < 0.01) and 0.62 (CI 95%, [0.56; 0.67]; p < 0.01), respectively. CONCLUSIONS: In a controlled hemorrhagic shock model in piglets, the correlation between SI and BDV seemed strong.

S100B serum level: A relevant biomarker for the management of non-traumatic headaches in emergency care?

BACKGROUND: The diagnostic of primary or secondary headaches in emergency units is mostly based on brain imaging, which is expensive and sometimes hardly accessible. An increase in serum S100B protein has already been found in several neurological conditions inducing brain damage. The objective of this study was to assess the diagnostic performance of S100B serum assay to distinguish primary and secondary headaches among patients with non-traumatic headaches in the emergency department. METHODS: This was a phase 2, prospective, monocentric diagnostic study. Eighty-one adult patients with non-traumatic headaches in the emergency department were included. In addition to the usual management, a blood assay of the S100B protein was performed in the emergency department, as well as a brain MRI between 48 and 96 h if not performed during the initial management. The primary or secondary headache diagnosis was made at one month by an expert committee, blindly of the results of the S100B assay. The primary outcome was the blood assay of the S100B protein. RESULTS: There was 63 patients for analysis in the primary headache group and 17 in the secondary headache group. The S100B protein assay was significantly higher in secondary headaches than primary headaches, with an AUC of the ROC curve of 0.67. The optimal threshold of 0.06 µg.L-1 allowed to obtain those diagnostic characteristics: sensitivity 75% [48; 93], specificity 62% [48; 74], PPV 35% [20; 54] and NPV 90% [76; 97]. The association between the S100B protein level and the onset of pain was significantly higher for patients with headaches <3 h. CONCLUSION: The assay of the S100B protein could be useful in the management of this pathology in emergencies. Future studies taking into account dosing time and etiologies could be conducted in order to refine its use in practice.

Angiotensin II induces reactive oxygen species, DNA damage, and T-cell apoptosis in severe COVID-19.

BACKGROUND: Lymphopenia is predictive of survival in patients with coronavirus disease 2019 (COVID-19). OBJECTIVE: The aim of this study was to understand the cause of the lymphocyte count drop in severe forms of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. METHODS: Monocytic production of reactive oxygen species (ROSs) and T-cell apoptosis were measured by flow cytometry, DNA damage in PBMCs was measured by immunofluorescence, and angiotensin II (AngII) was measured by ELISA in patients infected with SARS-CoV-2 at admission to an intensive care unit (ICU) (n = 29) or not admitted to an ICU (n = 29) and in age- and sex-matched healthy controls. RESULTS: We showed that the monocytes of certain patients with COVID-19 spontaneously released ROSs able to induce DNA damage and apoptosis in neighboring cells. Of note, high ROS production was predictive of death in ICU patients. Accordingly, in most patients, we observed the presence of DNA damage in up to 50% of their PBMCs and T-cell apoptosis. Moreover, the intensity of this DNA damage was linked to lymphopenia. SARS-CoV-2 is known to induce the internalization of its receptor, angiotensin-converting enzyme 2, which is a protease capable of catabolizing AngII. Accordingly, in certain patients with COVID-19 we observed high plasma levels of AngII. When looking for the stimulus responsible for their monocytic ROS production, we revealed that AngII triggers ROS production by monocytes via angiotensin receptor I. ROSs released by AngII-activated monocytes induced DNA damage and apoptosis in neighboring lymphocytes. CONCLUSION: We conclude that T-cell apoptosis provoked via DNA damage due to the release of monocytic ROSs could play a major role in COVID-19 pathogenesis.

Taxonomical and functional changes in COVID-19 faecal microbiome could be related to SARS-CoV-2 faecal load.

Since the beginning of the pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) the gastrointestinal (GI) tract has emerged as an important organ influencing the propensity to and potentially the severity of the related COVID-19 disease. However, the contribution of the SARS-CoV-2 intestinal infection on COVID-19 pathogenesis remains to be clarified. In this exploratory study, we highlighted a possible link between alterations in the composition of the gut microbiota and the levels of SARS-CoV-2 RNA in the gastrointestinal tract, which could be more important than the presence of SARS-CoV-2 in the respiratory tract, COVID-19 severity and GI symptoms. As established by metaproteomics, altered molecular functions in the microbiota profiles of high SARS-CoV-2 RNA level faeces highlight mechanisms such as inflammation-induced enterocyte damage, increased intestinal permeability and activation of immune response that may contribute to vicious cycles. Uncovering the role of this gut microbiota dysbiosis could drive the investigation of alternative therapeutic strategies to favour the clearance of the virus and potentially mitigate the effect of the SARS-CoV-2 infection.

Pneumothorax diagnosis with lung sliding quantification by speckle tracking: A prospective multicentric observational study.

INTRODUCTION: Lung ultrasound is commonly used for the diagnosis of pneumothorax. However, recognition of pleural sliding is subjective and can be difficult for novice. The primary objective was to compare a novices physician's performance in diagnosing pneumothorax from ultrasound (US) scans either with visual evaluation or with maximum longitudinal pleural strain (MLPS). The secondary objective was to compare the diagnostic relevance of US with visual evaluation or MLPS to diagnose pneumothorax with an intermediately experienced and an expert physician. METHODS: We conducted a prospective, observational study in two emergency department and two intensive care unit, between February 2019 and June 2020. We included 99 adult patients with suspected pneumothorax, who received a chest computed tomography (CT). Three physicians with different experience of interpreting US scans (a novice physician, an intermediately experienced physician, and an expert) analyzed the US scans of 99 patients with suspected pneumothorax (50 (51%) with confirmed pneumothorax), which were confirmed by CT scan. RESULTS: With a threshold of 5%, the MLPS sensitivity was 94% (95% CI [83%; 98%]), and the specificity was 100% (95% CI [93%; 100%]). The novice physician had an area under the curve (AUC) with visual analysis of 0.75 (95% CI [0.67; 0.83]) vs 0.86 (95% CI [0.79; 0.94]) with MLPS (p = 0.04). The intermediate physician's AUC for diagnosing pneumothorax with visual analysis was 0.93 (95% CI [0.88; 0.99]) vs 1.00 (95% CI [1.00; 1.00]) with MLPS (p < 0.01) and for the expert physician it was 0.98 (95% CI [0.95;1.00]) vs 0.97 (95% CI [0.93; 1.00]), respectively (p = 0.69). CONCLUSION: In our study, speckle tracking analysis improved the accuracy of US for the novice and the intermediate but not the expert sonographer in the diagnosis of pneumothorax.

Focal cardiac ultrasound learning with pocked ultrasound device: A bicentric prospective blinded randomized study.

PURPOSE: Point-of-care ultrasound using a pocket-ultrasound-device (PUD) is increasing in clinical medicine but the optimal way to teach focused cardiac ultrasound is not clear. We evaluated whether teaching using a PUD or a conventional-ultrasound-device (CUD) is different when the final exam was conducted on a PUD. The primary aim was to compare the weighted total quality scale (WTQS, out of 100) obtained by participants in the two groups (CUD and PUD) on a live volunteer 2-4 weeks after their initial training. The secondary aims were to compare examination time and students' confidence levels (out of 50). METHODS: This bicentric, prospective single-blind randomized trial included undergraduate medical students. After watching a 15 min video about echocardiography views, students had a 45 min hands-on training session with a live volunteer using a PUD or a CUD. The final examination was conducted with a PUD on a live volunteer. RESULTS: Eighty-six comparable students were included, with 4 ± 1 years of medical training. In the PUD group, the mean WTQS was 65 ± 16 versus 60 ± 15 in the CUD group [p = 0.22; in multivariate analysis, OR 0.8 95% CI (0.1;1.6), p = 0.34]. The examination time was 10.0 [6.2-12.4] min in the PUD group versus 11.4 [7.3-13.2] in the CUD group (p = 0.39), while the confidence level was 27.9 ± 7.7 in the PUD group versus 27.4 ± 7.2 in the CUD group (p = 0.76). CONCLUSION: There was no difference between teaching echocardiographic views using a PUD as compared to a CUD on the PUD image quality, exam time, or confidence level of students.

Magnetic needle-tracking device for ultrasound guidance of radial artery puncture: A randomized study on a simulation model.

INTRODUCTION: Ultrasound-guidance of radial artery catheter insertion improves the first attempt success and reduces the occurrence of hematomas. Needle-tracking devices optimize needle-ultrasound beam alignment by displaying in real-time the needle tip position. We compared the median time need by experienced physicians to achieve radial artery puncture using either a conventional ultrasonography device (CUD) or a magnetic needle-tracking ultrasound device (MUD) in a simulation training arm model. METHODS: Fifty experienced residents and physicians performed two punctures in randomized order with the CUD and the MUD. The primary outcome was puncture duration; the secondary outcomes were puncture success, rate of accidental vein puncture, and practitioner's comfort (subjective scale 0-10). RESULTS: The median [lower-upper quartile] puncture time was 10 [6-14] seconds when using CUD and 4 [3-7] seconds when using MUD (P < .01). In the multivariate analysis, MUD use was associated with decreased puncture duration whatever the puncture order (OR 1.13 [1.07-1.20], P < .01). The participants performed 99 (99%) successful punctures: 50 with the MUD (100%) and 49 with the CUD (98%). There was no accidental venous puncture. The practitioner's comfort level was 6.5 [6, 7] with the CUD and 8 [7-9] with the MUD (P < .01). CONCLUSION: MUD reduced radial artery puncture time and improved physician comfort in a simulation training arm model.

[Organisation and methods of intervention of the medical-psychological emergency units]. / Organisation et modalités d'intervention des cellules d'urgence médico-psychologique.

In the particular case of exceptional health situations involving multiple victims or not, the early psychiatric care of patients affected, directly or not, relies on the medical-psychological emergency cells (Cump). The organisation of these units is based on ministerial instructions. The indications for recourse to the Cump as well as the method of triggering it are based on recommendations established by French learned societies.

[Physical restraint of the adult patient with uncontrollable agitation]. / Contention physique du patient adulte présentant une agitation incontrôlable.

In the context of psychiatric emergencies, it is important to distinguish between so-called controllable agitation and uncontrollable agitation. In this context, physical restraint of the adult patient is sometimes necessary, but remain an exceptional measure. Restraints must be applied rapidly and in a protocolised manner. It should be used sparingly in the elderly patient. Physical restraint is a medical prescription that must be accompanied by chemical restraint.

[Plea for a collegial practice of emergency psychiatric care]. / Plaidoyer pour un exercice collégial du soin psychiatrique en urgence.

The care of patients, especially in the field of agitation or psychiatry, requires close coordination between different actors. Interdisciplinarity makes it possible to analyse and harmonise the links between various disciplines with the common aim of solving complex problems. This interdisciplinarity must now become a fundamental in the teaching of health sciences and a prerequisite for the functioning of hospital services, in particular in the formalisation of acute care pathways.

Diaphragmatic excursion measurement in emergency department patients with acute dyspnea to predict mechanical ventilation use.

INTRODUCTION: Ultrasound is a feasible and reproducible method for measuring right diaphragmatic excursion (RDE) in ED patients with acute dyspnea (AD). In AD patients, the correlation between the RDE value and the need for mechanical ventilation (MV) is not known. MATERIALS: This was a bicentric, observational prospective study. The RDE measurement was done at admission. The need for MV was defined by the use of MV within 4 h of AD management. An optimal threshold for RDE was determined as the value that minimized the incorrect predictions of the use of MV in the first 4 h as the highest Youden index. RESULTS: We analyzed 102 patients (79 [70; 86] years), 38 (37%) of whom had been ventilated. The RDE value was 1.7 cm [1.4; 2.0] and 2.2 cm [1.8; 2.6] in the ventilated and non-ventilated groups, respectively (p = 0.06). The AUC was 0.68 95% CI [0.57; 0.80]. With a threshold of 2 cm, the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were 76% [60%; 89%], 59% [46%; 71%], 81% [67%; 91%], and 53% [39%; 66%], respectively. In the non-COPD patients, the RDE values were 1.5 cm [1.2; 1.9] and 2.2 cm [1.8; 2.6] (p < 0.01) in the ventilated and not-ventilated groups, respectively. The AUC was 0.77 95% CI [0.64; 0.90]. With a threshold of 2.18 cm, the sensitivity, specificity, NPV, and PPV were 91% [71%; 99%], 51% [36%; 66%], 92% [75%; 99%], and 54% [38%; 69%], respectively. CONCLUSION: The RDE values at ED admission were unable to define a prognostic threshold value associated with subsequent MV need in the AD patients. In non-COPD patients, the NPV was 92%.

Minor Blunt Thoracic Trauma in the Emergency Department: Sensitivity and Specificity of Chest Ultralow-Dose Computed Tomography Compared With Conventional Radiography.

STUDY OBJECTIVE: To evaluate the diagnostic performance of chest ultralow-dose computed tomography (CT) compared with chest radiograph for minor blunt thoracic trauma. METHODS: One hundred sixty patients with minor blunt thoracic trauma were evaluated first by chest radiograph and subsequently with a double-acquisition nonenhanced chest CT protocol: reference CT and ultralow-dose CT with iterative reconstruction. Two study radiologists independently assessed injuries with a structured report and subjective image quality and calculated certainty of diagnostic confidence level. RESULTS: Ultralow-dose CT had a sensitivity and specificity of 100% compared with reference CT in the detection of injuries (187 lesions) in 104 patients. Chest radiograph detected abnormalities in 82 patients (79% of the population), with lower sensitivity and specificity compared with ultralow-dose CT (P<.05). Despite an only fair interobserver agreement for ultralow-dose CT image quality (κ=0.26), the diagnostic confidence level was certain for 95.6% of patients (chest radiograph=79.3%). Ultralow-dose CT effective dose (0.203 mSv [SD 0.029 mSv]) was similar (P=.14) to that of chest radiograph (0.175 mSv [SD 0.155 mSv]) and significantly less (P<.001) than that of reference CT (1.193 mSv [SD 0.459 mSv]). CONCLUSION: Ultralow-dose CT with iterative reconstruction conveyed a radiation dose similar to that of chest radiograph and was more reliable than a radiographic study for minor blunt thoracic trauma assessment. Radiologists, regardless of experience with ultralow-dose CT, were more confident with chest ultralow-dose CT than chest radiograph.

Arterial pH selectively predicts critical care needs in emergency department obese patients with acute dyspnea: A prospective comparative study.

INTRODUCTION: Obese patients with acute dyspnea may be prone to misorientation from the emergency department (ED), due to impaired gas exchange evaluation and altered basal respiratory profiles. This study aims to evaluate the prognostic value of arterial blood pH in obese ED patients with acute dyspnea in comparison to non-obese counterparts. METHODS: Single-center observational study of a cohort of 400 consecutive ED patients with acute dyspnea. The primary endpoint was a composite of Intensive Care Unit admission (with critical care needs) or in ED mortality. Predictors of the primary endpoint were assessed using multivariable logistic regression and ROC curve analysis, in obese (BMI ≥ 30 kg·m-2) and non-obese patients. RESULTS: 252 patients who had arterial blood gas testing were analyzed including 76 (30%) obese comparable to non-obese in terms of clinical history. 51 patients were admitted to ICU and 2 deceased before admission (20 obese (26%) vs 33 non-obese (19%); p = 0.17). Factors associated with ICU admission were arterial blood pH (pH < 7.36 vs pH ≥ 7.36) and gender. In multivariate models adjusted for risk factors, pH remained the sole independent predictor in obese patients, with no predictive value in non-obese patients (ROC AUC: 0.74, 95% CI [0.60; 0.87], optimal threshold for pH: 7.36, odds ratio: 10.5 [95% CI 3.18; 34.68]). CONCLUSION: Arterial blood pH may selectively predict critical care needs in ED obese patients with acute dyspnea, in comparison to non-obese. A falsely reassuring pH < 7.36 should be regarded as a marker of severity when assessing acute dyspnea in obese ED patients.

Out-of-hospital Times Using Helicopters Versus Ground Services for Emergency Patients.

OBJECTIVE: Minimizing out-of-hospital time reduces morbidity and mortality in patients with severe trauma, acute coronary syndrome, or acute stroke. Our objective was to compare out-of-hospital times by helicopter versus ground services when the estimated time of arrival on the scene was over 20 minutes. METHODS: We proposed a retrospective observational monocentric study following 2 cohorts. The helicopter group and the ground group included patients with severe trauma, acute coronary syndrome, or acute stroke transported by helicopter or ground services. RESULTS: Two hundred thirty-nine patients were included; 118 were in the ground group, and 121 were in the helicopter group. Distances for the helicopter group were higher (62.1 ± 22.5 km vs. 27.6 ± 10.4 km, P < .001). When distances were over 35 km, the helicopter group was faster. We identified distance, need for surgery, and intensive care hospitalization as 3 predicting factors for choosing helicopters over ground modes of transport. CONCLUSION: In cases of severe trauma, acute coronary syndrome, or acute stroke, emergency medical helicopter transport can be chosen over ground transport when patients are in a severe state and when the distance is further than 35 km from the hospital.

Integration of lung ultrasound in the diagnostic reasoning in acute dyspneic patients: A prospective randomized study.

INTRODUCTION: Misdiagnosis in acute dyspneic patients (ADP) has consequences on their outcome. Lung ultrasound (LUS) is an accurate tool to improve diagnostic performance. The main goal of this study was to assess the determinants of increased diagnostic accuracy using LUS. MATERIALS: Multicentre, prospective, randomized study including emergency physicians and critical care physicians treating ADP on a daily basis. Each participant received three difficult clinical cases of ADP: one with only clinical data (OCD), one with only LUS data (OLD), and one with both. Ultrasound video loops of A, B and C profiles were associated with the cases. Which physician received what data for which clinical case was randomized. Physicians assessed the diagnostic probability from 0 to 10 for each possible diagnosis. The number of uncertain diagnoses (NUD) was the number of diagnoses with a diagnostic probability between 3 and 7, inclusive. RESULTS: Seventy-six physicians responded to the study cases (228 clinical cases resolved). Among the respondents, 28 (37%) were female, 64 (84%) were EPs, and the mean age was 37±8 years. The mean NUDs, respectively, when physicians had OCD, OLD, and both were 2.9±1.8, 2.2±1.7, 2.2±1.8 (p = 0.02). Ultrasound data and ultrasound frequency of use were the only variables related to the NUD. Higher frequency of ultrasound use by physicians decreased the number of uncertain diagnoses in difficult clinical cases with ultrasound data (OLD or associated with clinical data). CONCLUSION: LUS decreases the NUD in ADP. The ultrasound frequency of use decreased the NUD in ADP clinical cases with LUS data.

Assessment of five different probes for lung ultrasound in critically ill patients: A pilot study.

INTRODUCTION: The present study was aimed at comparing the diagnosis concordance of five echo probes of lung ultrasound (LUS) with CT scans in intensive care and emergency patients with acute respiratory failure. MATERIALS: This prospective, observational, pilot study involved 10 acute patients in whom a thoracic CT scan was performed. An expert performed an LUS reference exam using five different probes: three probes with a high-quality conventional echo machine (cardiac phased-array probe, abdominal convex probe, linear probe) and two probes (cardiac and linear) with a pocket ultrasound device (PUD). Then, a trained physician and a resident performed 'blinded' analyses by viewing the video results on a computer. The primary objective was to test concordance between the blinded echo diagnosis and the CT scan. RESULTS: In the 100 LUS performed, the phased-array probe of the conventional machine and linear array probe of the PUD have the best concordance with the CT scan (Kappa coefficient=0.75 [CI 95%=0.54-0.96] and 0.62 [CI 95%=0.37-0.86], respectively) only for experts and trained physicians. The agreement was always poor for residents. Convex (abdominal) and linear transducers of conventional machines and the phased-array transducers (cardiac) of PUD have poor or very poor agreement, regardless of the physician's experience. CONCLUSION: Among the probes tested for LUS in acute patients, the cardiac probe of conventional machines and the linear probes of PUDs provide good diagnosis concordance with CT scans when performed by an expert and trained physician, but not by residents.

Compression with a pocket-sized ultrasound device to diagnose proximal deep vein thrombosis.

INTRODUCTION: Compression ultrasonography (CUS) is a validated technique for the diagnosis of deep venous thrombosis (DVT), but has never been studied with pocket-sized ultrasound device (PUD). The main objective of this study was to assess the diagnostic performance of CUS made by emergency physicians (EPs) using a PUD. MATERIALS: This was a prospective, diagnostic test assessment, single-center study. Patients underwent VCU performed by a trained EP with PUD (CUS-PUD) for searching proximal DVT (PDVT) and were then seen by an expert vascular physician who blindly performed a duplex venous ultrasound, which was the criterion standard. CUS-PUD's diagnostic performance was evaluated by sensitivity (Se), specificity (Sp), and positive and negative predictive values (PPV and NPV). RESULTS: The sample included 57 patients of whom 56 were analyzed. Eleven (20%) PDVT were diagnosed with CUS-PUD: 7 (64%) femoral and 4 (36%) popliteal. The CUS-PUD's Se was 100% [72%; 100%], Sp 100% [92%; 100%]. The PPV was 100% [74%; 100%], and the NPV was 100% [90%; 100%]. CONCLUSION: CUS-PUD performed with a pocket-sized ultrasound appears to be feasible in emergency practice for the diagnosis of proximal DVT. A study with a larger sample size will have to describe the accuracy.

Lung real time three-dimensional imaging in critically ill ventilated patients: a global diagnosis concordance study.

Lung ultrasound (LUS) increases clinical diagnosis performance in intensive care unit (ICU). Real-time three-dimensional (3-D) imaging was compared with two-dimensional (2-D) LUS by assessing the global diagnosis concordance. In this single center, prospective, observational, pilot study, one trained operator performed a 3-D LUS immediately after a 2-D LUS in eight areas of interest on the same areas in 16 ventilated critically ill patients. All cine loops were recorded on a computer without visible link between 2-D and 3-D exams. Two experts blindly reviewed cine loops. Four main diagnoses were proposed: normal lung, consolidation, pleural effusion and interstitial syndrome. Fleiss κ and Cohen's κ values were calculated. In 252 LUS cine loops, the concordance between 2-D and 3-D exams was 83.3% (105/126), 77.6% (99/126) and 80.2% (101/126) for the trained operator and the experts respectively. The Cohen's κ coefficient value was 0.69 [95% Confidence Interval (CI) 0.58-0.80] for expert 1 meaning a substantial agreement. The inter-rater reliability was very good (Fleiss' κ value = 0.94 [95% CI 0.87-1.0]) for 3-D exams. The Cohen's κ was excellent for pleural effusion (κ= 0.93 [95% CI 0.76-1.0]), substantial for normal lung diagnosis (κ = 0.68 [95% CI 0.51-0.86]) and interstitial syndrome (κ = 0.62 [95% CI 0.45-0.80]) and fair for consolidation diagnoses (κ = 0.47 [95% CI 0.30-0.64]). In ICU ventilated patients, there was a substantial concordance between 2-D and 3-D LUS with a good inter-rater reliability. However, the diagnosis concordance for lung consolidation is poor.

Role of the internet as an information resource before anaesthesia consultation: A French prospective multicentre survey.

BACKGROUND: Use of the internet as an information search tool has increased dramatically. Our study assessed preoperative use of the internet by patients to search for information regarding anaesthesia, surgery, pain or outcomes. OBJECTIVE(S): The aim of this study was to test whether patients used the internet prior to surgery and what kinds of information they looked for (anaesthetic technique, pain, adverse events, outcomes and surgery). Correlation between patient age and information sought about surgery from the internet was also explored. DESIGN: A prospective multicentre observational study. SETTING: In total, 14 French private and public institutions from May 2015 to January 2016. PATIENTS: In total, 3161 adult patients scheduled for elective surgery under regional or general anaesthesia. INTERVENTION(S): An anonymous questionnaire was presented to adult patients scheduled for elective surgery under regional or general anaesthesia for completion before the first meeting with the anaesthesiologist. The investigator at each centre completed specific items that the patient could not complete. MAIN OUTCOME MEASURES: We defined the primary endpoint as the number of patients who searched for information about their anaesthesia or surgery on the internet by the time of the their preanaesthetic consultation. RESULTS: Of the 3234 questionnaires distributed, responses were received from 3161 patients. Within this respondent sample, 1304 (45%) were professionally active and 1664 (59%) used the internet at least once per day. Among 3098 (98%) patients who answered the question concerning the primary endpoint, 1506 (48%) had searched the internet for information about their health. In total, 784 (25%) used the internet to find information about their surgery and 113 (3.5%) looked for specific information about anaesthesia. Of the 3161, 52% reported difficulty searching for appropriate information about anaesthesia on the internet. 'Daily use of the web' [odds ratio (OR) 2.0; (95% CI: 1.65 to 2.55) P < 0.001], 'use of the web on mobile devices' [OR 1.24; (95% CI: 1.02 to 1.50) P = 0.02] and 'asking general practitioner or surgeon about information' [OR 1.35; (95% CI: 1.11 to 1.64) P = 0.002] were significantly associated with the primary endpoint. CONCLUSION: The internet was not widely used by patients scheduled for elective surgery to search for information about anaesthesia and surgery in our French multicentre study. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02442609.