ICU survival and need of renal replacement therapy with respect to AKI duration in critically ill patients.

BACKGROUND: Transient and persistent acute kidney injury (AKI) could share similar physiopathological mechanisms. The objective of our study was to assess prognostic impact of AKI duration on ICU mortality. DESIGN: Retrospective analysis of a prospective database via cause-specific model, with 28-day ICU mortality as primary end point, considering discharge alive as a competing event and taking into account time-dependent nature of renal recovery. Renal recovery was defined as a decrease of at least one KDIGO class compared to the previous day. SETTING: 23 French ICUs. PATIENTS: Patients of a French multicentric observational cohort were included if they suffered from AKI at ICU admission between 1996 and 2015. INTERVENTION: None. RESULTS: A total of 5242 patients were included. Initial severity according to KDIGO creatinine definition was AKI stage 1 for 2458 patients (46.89%), AKI stage 2 for 1181 (22.53%) and AKI stage 3 for 1603 (30.58%). Crude 28-day ICU mortality according to AKI severity was 22.74% (n = 559), 27.69% (n = 327) and 26.26% (n = 421), respectively. Renal recovery was experienced by 3085 patients (58.85%), and its rate was significantly different between AKI severity stages (P < 0.01). Twenty-eight-day ICU mortality was independently lower in patients experiencing renal recovery [CSHR 0.54 (95% CI 0.46-0.63), P < 0.01]. Lastly, RRT requirement was strongly associated with persistent AKI whichever threshold was chosen between day 2 and 7 to delineate transient from persistent AKI. CONCLUSIONS: Short-term renal recovery, according to several definitions, was independently associated with higher mortality and RRT requirement. Moreover, distinction between transient and persistent AKI is consequently a clinically relevant surrogate outcome variable for diagnostic testing in critically ill patients.

Haemorrhagic shock, therapeutic management.

The management of a patient in post-traumatic haemorrhagic shock will meet different logics that will apply from the prehospital setting. This implies that the patient has beneficiated from a "Play and Run" prehospital strategy and was sent to a centre adapted to his clinical condition capable of treating all haemorrhagic lesions. The therapeutic goals will be to control the bleeding by early use of tourniquet, pelvic girdle, haemostatic dressing, and after admission to the hospital, the implementation of surgical and/or radiological techniques, but also to address all the factors that will exacerbate bleeding. These factors include hypothermia, acidosis and coagulopathy. The treatment of these contributing factors will be associated to concepts of low-volume resuscitation and permissive hypotension into a strategy called "Damage Control Resuscitation". Thus, the objective in situation of haemorrhagic shock will be to not exceed a systolic blood pressure of 90 mmHg (in the absence of severe head trauma) until haemostasis is achieved.

[Diagnosis and treatment of trauma-induced coagulopathy]. / Diagnostic et prise en charge de la coagulopathie post-traumatique.

Trauma-induced coagulopathy is frequent and complex, and is responsible for an impairment of trauma outcome. Diagnosis of trauma coagulopathy is usually done with standard biology but recently new technics arose and gave us the opportunity to have faster information on coagulopathy with quick INR measure or clot formation study with thrombelastometry. Treatment of the coagulopathy should be done earlier in the course of trauma. Two strategies are possible that include either the association of RBC, platelet and FFP in a predefined ratio, or the use of factor concentrates guided with thrombelastometry. Treatment of favouring factors such as hypothermia, acidosis and hypocalcemia is also mandatory.

Residents and ICU nurses get reliable static and dynamic haemodynamic assessments with aortic oesophageal Doppler.

BACKGROUND: Aortic oesophageal Doppler (ODM) allows continuous non-invasive haemodynamic monitoring. We tested to confirm if residents and nurses were able to reposition oesophageal probe (OP), obtain aortic blood flow of good quality and so perform reliable static and dynamic haemodynamic assessments. METHODS: Prospective observational study assessing ODM measurements were obtained by six residents and three nurses after they have participated in training. Measured (aortic diameter) and calculated haemodynamic data [indexed stroke volume (SVI), cardiac index] were directly obtained from ODM, after residents and nurses repositioned the OP. In a second group of patients, we tested the ability of residents and nurses to detect rapid haemodynamic changes after a passive leg raising. SVI comparison was the primary end point. Statistical analysis was performed using the method of Bland and Altman. RESULTS: Sixty-six haemodynamic measurements were performed on 42 patients. Mean bias for SVI between the skilled physician and residents, and between the skilled physician and nurses were -0.9 ± 5.2 ml/m(2) (P = 0.15), with a percentage error of 31%, and 0.9 ± 5.1 ml/m(2) (P = 0.14), with a percentage error of 33%, respectively. There was an excellent correlation for SVI between the physician and residents (r = 0.9; P < 0.0001) and between the physician and nurses (r = 0.9; P < 0.0001). Induced changes in SVI measured by residents and nurses strongly followed those of our skilled physician. CONCLUSION: Residents and nurses get reliable static and dynamic haemodynamic assessments with ODM compared to our skilled physician.

[Recurrent systemic embolism: look for a thrombus in... the thoracic aorta]. / Embolies systémiques récidivantes: chercher le thrombus dans... l'aorte.

Thoracic aortic mural thrombus is a rare entity and potential source of serious systemic emboli. The progress of computed tomography (CT) angiography and the current use of transesophageal echocardiography (TEE) after any embolic event have considerably increased the frequency of diagnostic and there is a growing interest about the etiopathogenesis, which is still widely misunderstood. Therapeutic management remains controversial. We present a case of floating thrombus in the thoracic aorta detected by contrast-enhanced CT scan. This thrombus was responsible for two close major embolic events and was therefore managed surgically. Finally, outcome was favorable.

[Coronary stents and anaesthesia: it is time to have national data]. / Stents coronariens et anesthésie: il est temps d'avoir des données nationales.

We report 13 cases of coronary stent patients, undergoing a non cardiac surgery. Despite an heterogenous perioperative management of antiplatelet agents, none of these patients developed any significant complications. Recently, several case reports of postoperative drug eluting stent thrombosis have been reported. However, the actual incidence of this dramatic event is not known. This confirms the need to perform prospective studies or registries of patients with coronary stents undergoing non cardiac surgery, in order to propose evidence-based recommendations on perioperative antiplatelet management in such patients.

[Transorbital fiberoptic intubation: a predictable difficult intubation in cephalic surgery]. / Intubation transorbitaire: une intubation difficile prévisible en chirurgie céphalique.

Management of the difficult adult airway is a crucial problem in anaesthesia. It is the first cause of anaesthetic mortality and morbidity. We report here the case of a patient who could only be intubated through the orbital cavity. We discuss our technique of intubation compared to the other rare procedures described in the literature. We also focus on our anaesthetic protocol and the interest of preserving spontaneous ventilation for intubation. Use of short acting anaesthetic drugs can help to achieve such conditions.

Effects of peptide therapy on ex vivo T-cell responses.

BACKGROUND: Peptide therapy targets T cells directly with short peptides containing multiple T-cell receptor epitopes. Murine studies suggest T-cell anergy as the mechanism of action; however, changes in T-cell cytokine profiles may be more relevant in human beings. OBJECTIVE: We sought to study the effects of peptide therapy on ex vivo antigen-specific T-cell responses. METHODS: Antigen-specific T-cell lines were generated from subjects enrolled in a double-blind, placebo controlled, two-dose study of the ALLERVAX CAT therapeutic, containing Fel d 1 peptides (ImmuLogic Pharmaceutical Corp., Waltham, Mass.) (n = 7, 8, and 7, respectively, for groups receiving placebo, 75 microg, or 750 microg). Each subject had three lines propagated before and after receiving peptide therapy; antigens used were cat hair extract, Fel d 1 peptides, and tetanus toxoid (negative control). Proliferative responses and cytokine generation from each line were assessed after two restimulations with antigen and autologous antigen-presenting cells. RESULTS: The Fel d 1 peptide lines showed a dose-dependent decrease of IL-4 production (p = 0.02 and 0.025, respectively, for the 750 microg group vs both the 75 microg and placebo groups). IL-4 production from the cat hair allergen extract lines and interferon-gamma production from both the Fel d 1 peptide lines and cat hair allergen extract lines showed no statistically significant changes. The control tetanus toxoid lines showed no changes in cytokine production; there were no significant changes in proliferation with any of the antigens in any of the treatment groups. In the clinical arm of the trial, only the 750 microg dose of peptides produced a significant response. CONCLUSIONS: Peptide therapy induces a significant, dose-dependent decrease in peptide-stimulated IL-4 production, consistent with either a shift in T-cell phenotype or peptide-specific T-cell tolerance.

[Analysis of the behavior of the coach in relation to violence in minor league hockey]. / Analyse des comportements de l'entraîneur par rapport à la violence au hockey mineur.

The purpose of this study was to verify if, during games, the behavior of ice hockey coaches at the bantam level tends to incite players to use roughness and to infringe upon the rules of the game, as the Néron report (1977) states. The video recording of 27 games using a split-screen technique made it possible to view simultaneously the players in action as well as the coaches' behavior. Analysis of the videotapes revealed that the coaches (n = 11) at the bantam level often exhort their players to put more intensity in their physical contacts (legal body checking), but they more often encouraged them to control themselves and avoid penalties. In general, the coaches displayed very little behavior that encouraged violent actions from the players.

Release of calcium from intracellular stores in rat basophilic leukemia cells monitored with the fluorescent probe chlortetracycline.

Release of calcium from intracellular stores of rat basophilic leukemia cells was monitored using the fluorescent probe chlortetracycline. The ability of chlortetracycline to indicate release from intracellular calcium stores was initially validated. The decrease of chlortetracycline fluorescence upon antigen-stimulation was not the result of secretion of granule-associated dye or of changes in the properties of the membranes. The chlortetracycline fluorescence signal was not influenced by Ca2+ influx across the plasma membrane. Results obtained from these chlortetracycline fluorescence measurements corresponded well with 45Ca efflux data, an indirect measurement of release of calcium from stores. Chlortetracycline was used to examine the rate of antigen-induced release of calcium from stores, the depletion of intracellular calcium stores by EGTA, and the relationship between the antigen-stimulated release of stored calcium and exocytosis. Chlortetracycline was shown to be a useful qualitative indicator for the release of intracellular calcium with a relatively rapid response time.

Retinal dopamine sensitivity to MPP+ toxicity: electrophysiological and biochemical evaluation.

This study concerns the effect of intravitreal injection of 1-methyl-4-phenylpyridinium ion (MPP+) on the electroretinograms (ERG) and on the levels of retinal dopamine (DA) in rabbits. The right eye was injected intravitreously with MPP+ while the other received only the vehicle and served as control. The administration of 7, 40, 70 or 700 micrograms MPP+ resulted in a dose-related decrease of the amplitude of the a and b-waves as well as the oscillatory potentials (OPs) of the ERG, down to extinction. In contrast, the retinal DA content was decreased only with the 700 micrograms MPP+ dose. Fluorescein angiography demonstrated abnormalities in the retinal circulation of all MPP+-treated eyes. These observations indicate that MPP+ causes lesions to the retinal vessels at doses non-toxic to the retinal dopaminergic neurons. These data suggest that intravitreal injection of MPP+ cannot be used to study the physiological role of retinal DA.

Different sensitivities to MPTP toxicity in primate nigrostriatal and retinal dopaminergic systems: electrophysiological and biochemical evidence.

The influences of N-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) on dopamine content in the retina and the striatum of monkeys, as well as retinal responses to flash stimulation were studied. Dopamine depletion was observed in the striatum, while retinal dopamine content was similar to controls. The electroretinograms and the oscillatory potentials remained normal, even in monkeys presenting a severe Parkinsonian syndrome, in concordance with the biochemical data. It is proposed that the retinal dopaminergic system is less sensitive to the toxic effects of MPTP than the nigro-striatal pathway.

Human endothelial cells prolong eosinophil survival. Regulation by cytokines and glucocorticoids.

Many recent studies have established the eosinophil as an active proinflammatory participant in a variety of disease states, most notably in allergic and helminthic disorders. In order to understand the effector role of eosinophils, factors which promote a selective eosinophilic infiltrate must be delineated. Eosinophil adherence to vascular endothelium is the first step in the formation of such an infiltrate. However, studies thus far have failed to identify factors which selectively activate the adherence of eosinophils. We have therefore speculated that the selective enrichment of eosinophils may result from nonselective recruitment of several leukocyte types combined with the production of local factors that promote the survival of eosinophils and not of other cells. We report that endothelial cell-conditioned medium selectively prolongs eosinophil survival up to 6 days in culture in a dose- and time-dependent manner. Stimulation of human vascular endothelial cells with IL-1 caused an increase in the generation of eosinophil survival-promoting activity, whereas stimulation with platelet-activating factor did not. Supernatants from human vascular endothelial cells cultured for 48 h in the presence of the glucocorticoid, dexamethasone, were less active in promoting eosinophil survival than control supernatants. These results suggest that factors produced locally in the vascular microenvironment may selectively promote eosinophil survival and may be under the regulation of cytokines and glucocorticoids.

IgE-dependent regulation of human basophil adherence to vascular endothelium.

Mechanisms favoring the recruitment of circulating human basophils to extravascular sites of allergic inflammation are unknown. The basophil secretagogues anti-IgE, and pollen allergens rye grass I and ragweed Ag E (Lol p I and Amb a I) were tested for their ability to promote basophil adherence to umbilical vein endothelial cells. Co-incubation of endothelial cells and basophils with anti-IgE resulted in time and dose-dependent increases in basophil adhesion. These effects were due to activation of the basophil, required both magnesium and calcium, occurred before or in the absence of histamine release, and were seen at concentrations of stimulus below the usual range of secretagogue activity. In contrast, anti-IgE or Ag stimulation of neutrophils, or basophils from donors non-responsive to anti-IgE or Ag with respect to histamine release, had no effect on cell adherence. mAb 60.3, recognizing the CD18 leukocyte adhesion molecule, inhibited anti-IgE-induced enhancement of basophil-endothelial cell binding. Exposure of basophils to low concentrations of Ag in vivo may selectively initiate basophil infiltration into tissue sites of allergic inflammation by enhancing their adherence to endothelium.

Body Checking in Pee Wee Hockey.

In brief: Two separate studies were done to determine the effects of body checking at the Pee Wee level. Study 1 evaluated eight of the smallest and eight of the largest players from leagues that allowed body checking. The players were measured for height, weight, grip strength, maximal skating speed, impact force during a body check, and speed of skating at impact. Significant morphologic differences (p <.05) between small and large players were reflected in forces of impact. Study 2 investigated the incidence and types of injuries sustained among players competing in leagues with body checking and without. In the checking leagues 55.5% of all injuries were due to body contacts, and serious injuries occurred six times more often than in nonchecking leagues. In addition, body checking accounted for 88% of the 25 fractures recorded during one hockey season.

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Alteration of monkey retinal oscillatory potentials after MPTP injection.

We have investigated the functional role of dopamine in the monkey retina by recording the retinal responses to flash stimulations before and after destruction of dopaminergic cells by intravenous injection of N-methyl-4-phenyl-1, 2, 3, 6-tetrahydropyridine (MPTP). We evaluated specifically the oscillatory potentials (100 Hz-3 KHz) of the electroretinogram. By day 47 after MPTP injection, a selective decrease of the amplitude of the first oscillatory potential was observed. At that time the animals had been receiving antiparkinsonian therapy since day 15. These results suggest that retinal dopaminergic neurons may play a role in the generation of the first oscillatory potential, and moreover, that each oscillatory potential should be considered individually.

In vitro intestinal absorption of glycine and L-alanine by rainbow trout, Salmo gairdnerii, Rich.

Tissue accumulation and serosal transfer of glycine and L-alanine have been studied in vitro in trout with duodenal, ileal and posterior portions of the intestine. Neither tissue accumulation nor serosal transfer was stimulated by mucosal glucose. The absorptive capacity of the three portions was different. The various modes of expression of the results (i.e. with respect to fresh weight, length or surface) lead to different conclusions regarding the so-called specialization of the portions.