A narrative review of family members' experience of organ donation request after brain death in the critical care setting.

INTRODUCTION: Family members of critically ill patients suffer from high levels of anxiety and depression in the ICU, and are at risk of developing post-ICU syndrome following ICU discharge. In the case of brain death, and potential organ donation, the family is at the center of the decision process: within a limited time frame, the family will be informed that the patient is brain-dead and will be approached about potential organ donation. MATERIALS AND METHODS: Family experience with organ donation has been the topic of several research papers allowing one to gain knowledge about family members' experience of organ donation, emphasizing specific needs, adequate support, and pointing out gaps in current delivery of family-centered care. In this narrative review, experts, clinicians, and researchers present the various legal systems regarding family implication in organ donation decisions; describe factors that influence the decision-making process; highlight family perspectives of care and respect for potential donors in the ICU environment; describe the impact of organ donation discussions and decisions on post-ICU syndrome; and suggest communication skills and support to be developed in the future. A research agenda for the next decade is also encouraged. CONCLUSION: Overall, challenges remain and concern all persons involved in the process, ICU doctors and nurses, the organ procurement organization, family members, and, in some cases, the patients themselves. Looking at the big picture will provide opportunities for further improvements.

3,4-dihydroxybenzalacetone and caffeic acid phenethyl ester induce preconditioning ER stress and autophagy in SH-SY5Y cells.

3,4-dihydroxybenzalacetone (DBL) and Caffeic acid phenethyl ester (CAPE) are both catechol-containing phenylpropanoid derivatives with diverse bioactivities. In the present study, we analyzed the ability of these compounds to activate the unfolded protein response (UPR) and the oxidative stress response. When human SH-SY5Y neuroblastoma cells were treated with DBL or CAPE, the expression of endoplasmic reticulum (ER) stress-related genes such as HSPA5, HYOU1, DDIT3, and SEC61b increased to a larger extent in response to CAPE treatment, while that of antioxidant genes such as HMOX1, GCLM, and NQO1 increased to a larger extent in response to DBL treatment. DNA microarray analysis confirmed the strong link of these compounds to ER stress. Regarding the mechanism, activation of the UPR by these compounds was associated with enhanced levels of oxidized proteins in the ER, and N-acetyl cysteine (NAC), which provides anti-oxidative effects, suppressed the induction of the UPR-target genes. Furthermore, both compounds enhanced the expression of LC3-II, a marker of autophagy, and 4-Phenylbutyric acid (4-PBA), a chemical chaperone that reduces ER stress, suppressed it. Finally, pretreatment of cells with DBL, CAPE or low doses of ER stressors protected cells against a neurotoxin 6-hydroxydopamine (6-OHDA) in an autophagy-dependent manner. These results suggest that DBL and CAPE induce oxidized protein-mediated ER stress and autophagy that may have a preconditioning effect in SH-SY5Y cells.

[Differential diagnosis of status epilepticus in intensive care: about one case of sporadic Creutzfeldt-Jakob]. / Diagnostic différentiel d'un état de mal épileptique en réanimation: à propos d'un cas de Creutzfeldt-Jakob sporadique.

A 78-year-old man was admitted in the intensive care unit for epilepsy seizure (tonic-clonic seizure). Since three months, his wife reports motor dysfunction (weakness) and since two weeks, rapidly progressive changes in cognition (apraxia, akinetic mutism). The diagnosis of probable sporadic Creutzfeldt-Jakob on the basis of clinical, EEG and MRI lesions was made. Refining diagnostic criteria is probably needed, including the usefulness of repeated MRI with FLAIR and diffusion-weighted imaging.

[Evolution of the access to the kidney transplantation in France of foreign patients and French patients living in overseas territories]. / Évolution de l'accès à la greffe rénale en France des patients étrangers ou résidant outre-mer.

In France, foreign patients, whether resident or not in France, can register on the national waiting list under administrative and financial conditions. We performed a retrospective analysis to evaluate the access to kidney transplantation on a cohort 2004-2008, using the national registry. Among the 14,732 patients registered during this period, 15.3% are of non-French nationality (3.4% other European, 5.9% North African, 3.9% sub-Saharan African, 2.9% other). Among the 84.6% of French nationality, 3.3% are living in French overseas territories. Compared to the 17.6-month median waiting time of the cohort, median waiting time differs significantly between groups, from 15.7 months for mainland French patients to 36 months for sub-Saharan African patients. Despite the regular development of the allocation rules, these disparities in access to transplantation are mainly, but not completely, explained by blood group or HLA matching difficulties. After adjustment for the other factors known to be significantly linked to a difficult access to transplantation, North and sub-Saharan African patients have the worst difficulties. Future research should consider nonmedical factors, such as socio-economic or socio-cultural factors, potentially relevant to avoid disparities in access to transplantation and should aim at developing specific interventions.

[Quality of life of living kidney donor: a national report]. / Rapport qualité de vie des donneurs vivants de rein. Étude QV DVR transversale.

The renal transplantation is nowadays the reference treatment of ESRD. Living donor kidney transplantation is less often performed in France than in other countries. Nevertheless, numerous French and international surveys have evidenced that it provides the recipients a longer life expectancy and a better quality of life. Donors themselves, what do they become? How are they? For the first time in France, a survey has been implemented to investigate the quality of life of living kidney donor to one of their close relations. This study has been undertaken by the Agency of the biomedecine and the service Clinical Epidemiology and Evaluation (EEC), of the University teaching hospital of Nancy. The main objective was to describe the quality of life of the living donors having given a kidney for more than a year and less than 5 years. The secondary objective was to contribute to the knowledge of the main factors associated to the living kidney donor quality of life, one year after the donation. Participants had to be living in France at the time of the donation which had taken place between June 30(th), 2005 and March 1(st), 2009. A folder gathering various self-administrated questionnaires was sent to the place of residence of the donor between March and April, 2010. These data were completed by medical data collected near the transplantation centres by the Agency of biomedecine within the framework of the register CRISTAL. They included the characteristics of the donation and of the donor at the very time of the donation, 3 months after the donation and at the last annual assessment. Three living donors in four, that is 501 persons, agreed to fully participate. They constituted a representative national sample of all the living donors of this period. The non participants were younger (4.5 years on average) and had a less adequate annual follow-up. The women were more represented (61 %) than men. The median age was 53 years. More of 2/3 were employed at the time of the survey. The three main categories of donors were ascendants (36 %), collateral (33 %) and spouses (26%). The donation decision was taken without hesitation (94 %) and at an early stage of the evolution of the recipient renal disease (64 %). The delivered information was considered globally satisfactory except for the painful consequences and for the scar. The living donors were, long after their donation, in an excellent physical health state according to the SF36 summarized physical score and this especially when they were old as compared to the same age and sex general population. This phenomenon highlights the drastic selection of the potential donors. The only factor influencing the level of long term physical health was the surgical technique: the 261 subjects having undergone a coelioscopy had less often presented post operative pain (OR=0.5; 0.3-0.8; P<0.002) and had more often recovered completely without any residual pain (OR=1.7; 1.2-2.5; P<0.004). The quality of life mental dimension according to the SF36 summarized mental score was very close to that of the same age and sex of the general population although a slightly lower. It is influenced by characteristics related to the way the donation had been lived, particularly the understanding of their donation by their circle of acquaintances (average score 74.2/100), the perception of a feeling of owing on behalf of the recipient (46.5 %) and the fact of having lived a competition to be retained as the donor (for 266 cases another potential donor did exist and 21 lived the donation as a strong competition). More than 84 % of the donors was still followed by a healthcare professional at the time of the survey. The main expressed complaints concern the quality of the medical follow-up (70 donors expressed themselves openly on this topic) and the pain and scar after effects of the intervention. In spite of the surgical complications, of the dissatisfactions regarding their medical follow-up, of dismissals or of necessary adjustments of their professional life (13 %), of their difficulties to carry heavy loads, of sometimes complex relations with the recipient (23 % positive, 10 % negative) or their circle of acquaintances, of expenses non reimbursement and of losses of salary (12 %), they would be 95 % to recommend the donation and if it was to be redone 98 % would do it again! Benefits brought to the recipient won largely over the encountered difficulties. This retrospective and cross-sectional study allows to state recommendations which have to be confirmed by the 2009-2012 longitudinal study: to favour the coelioscopy which offers an advantage in terms of less frequent pain and a better post operative recovery, to better understand the phenomena of competition between potential and donors recipients, to improve the information about the potential consequences of the donation on the pain and on the scar, to inform the donor about the importance to associate the proxies with the decisionmaking or at least with the discussion and finally to improve the society recognition of the donation.

[Sedation and analgesia assessment tools in ICU patients]. / Quels sont les outils d'évaluation de la sédation et de l'analgésie?

Sedative and analgesic treatment administered to critically ill patients need to be regularly assessed to ensure that predefinite goals are well achieved as the risk of complications of oversedation is minimized. In most of the cases, which are lightly sedation patients, the goal to reach is a calm, cooperative and painless patient, adapted to the ventilator. Recently, eight new bedside scoring systems to monitor sedation have been developed and mainly tested for reliability and validity. The choice of a sedation scale measuring level of consciousness, could be made between the Ramsay sedation scale, the Richmond Agitation Sedation scale (RASS) and the Adaptation to The Intensive Care Environment scale-ATICE. The Behavioral Pain Scale (BPS) is a behavioral pain scale. Two of them have been tested with strong evidence of their clinimetric properties: ATICE, RASS. The nurses'preference for a convenient tool could be defined by the level of reliability, the level of clarity, the variety of sedation and agitation states represented user friendliness and speed. In fine, the choice between a simple scale easy to use and a well-defined and complex scale has to be discussed and determined in each unit. Actually, randomized controlled studies are needed to assess the potential superiority of one scale compared with others scales, including evaluation of the reliability and the compliance to the scale. The usefulness of the BIS in ICU for patients lightly sedated is limited, mainly because of EMG artefact, when subjective scales are more appropriated in this situation. On the other hand, subjective scales are insensitive to detect oversedation in patients requiring deep sedation. The contribution of the BIS in deeply sedation patients, patients under neuromuscular blockade or barbiturates has to be proved. Pharmacoeconomics studies are lacking.

Sedation, sucralfate, and antibiotic use are potential means for protection against early-onset ventilator-associated pneumonia.

To examine risk factors for early-onset ventilator-associated pneumonia (EOP) in patients requiring mechanical ventilation (MV), we performed a prospective cohort study that included 747 patients. Pneumonia was defined as a positive result for a protected quantitative distal sample. EOP was defined as pneumonia that occurred from day 3 to day 7 of MV. Eighty patients (10.7%) experienced EOP. Independent predictors of EOP were male sex (odds ratio [OR], 2.06; 95% confidence interval [CI], 1.18-3.63), actual Glasgow Coma Scale value of 6-13 (OR, 1.95; 95% CI, 1.2-3.18), high Logistic Organ Dysfunction score at day 2 (OR, 1.12 per point; 95% CI, 1.02-1.23), unplanned extubation (OR, 3.19; 95% CI, 1.28-7.92), and sucralfate use (OR, 1.81; 95% CI, 1.01-3.26). Protection occurred with use of aminoglycosides (OR, 0.36; 95% CI, 0.17-0.76), beta -lactams and/or beta -lactamase inhibitors (OR, 0.47; 95% CI, 0.28-0.83), or third-generation cephalosporins (OR, 0.33; 95% CI, 0.16-0.74). Sucralfate use and unplanned extubation are independent risk factors for EOP. Use of aminoglycosides, beta-lactams/ beta-lactamase inhibitors, or third-generation cephalosporins protects against EOP.

Epidemiology of Pseudomonas aeruginosa and risk factors for carriage acquisition in an intensive care unit.

Because of a high prevalence of Pseudomonas aeruginosa infections, we conducted an epidemiological study to assess the need for systematic surveillance, as well as the value of applying barrier precautions toP. aeruginosa carriers. From July 1997 to February 1998, we conducted a prospective cohort study in an 18-bed medical intensive care unit (ICU), which is part of the infectious diseases department in a 1200-bed tertiary-care teaching hospital. Rectal and oropharyngeal swabs were obtained on admission and twice weekly. Acquired strains were genotypically characterized by pulsed-field gel electrophoresis (PFGE). A risk factor analysis for carriage, colonization and infection was performed. Among 269 eligible patients, 116 (43%) were P. aeruginosa carriers, with 46 (17%) detected on admission and 70 (26%) who acquired carriage during their stay in ICU. Among these 70 patients, 29 became colonized (N=13) or developed infection (N=16). Conversely, in the 121 patients who remained free of carriage, no colonization or infection were detected. Genotyping analysis using PFGE was performed for 81/85 (95%) acquired strains in 67 patients. The same genotype I was observed for 58/81 (70%) of these strains issued from 47 patients, and a distinct genotype II affected two other patients (three strains). The last 20 strains were not genetically related. In a multivariate model, mechanical ventilation was associated with the acquisition of P. aeruginosa carriage. Antibiotics ineffective against P. aeruginosa significantly increased the risk of colonization or infection in ICU. Although several recent studies concluded that endogenous sources account for the majority of P. aeruginosa colonizations or infections, we conclude that epidemiology may vary according to the ICU, and that cross-colonization (i.e., exogenous source) may occur and warrant reinforced barrier precautions.

Compliance with triage to intensive care recommendations.

DESIGN: Recommendations for triage to intensive care units (ICUs) have been issued but not evaluated. SETTING: In this prospective, multicenter study, all patients granted or refused admission to 26 ICUs affiliated with the French Society for Critical Care were included during a 1-month period. Characteristics of participating ICUs and patients, circumstances of triage, and description of the triage decision with particular attention to compliance with published recommendations were recorded. RESULTS: During the study period, 1,009 patients were and 283 were not admitted to the participating ICUs. Refused patients were more likely to be older than 65 yrs (odds ratio [OR], 3.53; confidence interval [CI], 1.98-5.32) and to have a poor chronic health status (OR, 3.09; CI, 2.05-4.67). An admission diagnosis of acute respiratory or renal failure, shock, or coma was associated with admission, whereas chronic severe respiratory and heart failure or metastatic disease without hope of remission were associated with refusal (OR, 2.24; CI, 1.38-3.64). Only four (range, 0-8) of the 20 recommendations for triage to ICU were observed; a full unit and triage over the phone were associated with significantly poorer compliance with recommendations (0 [0-2] vs. 6 [2-9], p =.0003; and 1 [0-6] vs. 6 [1-9], p <.0001; respectively). CONCLUSION: Recommendations for triage to intensive care are rarely observed, particularly when the unit is full or triage is done over the phone. These recommendations may need to be redesigned to improve their practicability under real-life conditions, with special attention to phone triage and triaging to a full unit.

Appropriate use of restricted antimicrobial agents in hospitals: the importance of empirical therapy and assisted re-evaluation.

We evaluated the appropriateness of use of restricted antimicrobial agents in the context of a newly implemented order form and delivery system for restricted antimicrobial agents, using sequential prospective audits of prescriptions. Four antimicrobial agents were selected: glycopeptides (61 prescriptions), ciprofloxacin (42), piperacillin-tazobactam (42) and imipenem- cilastatin (47). The justification and adequacy of the antibiotic or combination used, reassessment of therapy and duration of treatment were appraised with reference to the clinical situation and hospital's guidelines. Of the 192 prescriptions, 30 (16%) were empirical therapy, 95 (49%) empirical and secondarily documented and 67 (35%) initially documented therapy. Overall, 73% of prescriptions conformed to guidelines, but the adequacy varied from 93% for vancomycin to only 38% for ciprofloxacin. Of 83/157 initially inadequate prescriptions, 42 (51%) were switched according to guidelines, but only 14% of ciprofloxacin prescriptions were adapted later. An intervention audit with counselling on ciprofloxacin usage increased this rate to 75%. Although implementation of the guidelines resulted in a marked reduction in overall antimicrobial costs, inappropriate antibiotic usage may persist for some drugs despite restricted access. These results emphasize the need for combined interventions using education and expert counselling, targeted to classes of antibiotic for which inappropriate usage is most common.

Hemodynamic tolerance of intermittent hemodialysis in critically ill patients: usefulness of practice guidelines.

Poor hemodynamic tolerance of intermittent hemodialysis (IHD) is a common problem for patients in an intensive care unit (ICU). New dialysis strategies have been adapted to chronic hemodialysis patients with cardiovascular insufficiency. To improve hemodynamic tolerance of IHD, specific guidelines were progressively implemented into practice through the year 1996 in our 26-bed medical ICU. To evaluate the efficiency of these guidelines we retrospectively compared all IHD performed during the years before (1995) and after (1997) implementation of these recommendations. Forty-five patients underwent 248 IHD sessions in 1995 and 76 patients underwent 289 IHD sessions in 1997. The two populations were similar for age, sex, chronic hemodialysis (26% versus 17%), and secondary acute renal failure. In 1997, patients were more severely ill with a higher SAPS II (50 +/- 17 versus 59 +/- 24; p = 0.036), and more patients required epinephrine or norepinephrine infusion before dialysis sessions (16% versus 34%; p < 0.0001). The compliance to guidelines was high, inducing a significant change in IHD modalities. As a result, hemodynamic tolerance was significantly better in 1997, with less systolic blood pressure drop at onset (33% versus 21%, p = 0. 002) and during the sessions (68% versus 56%, p = 0.002). IHD with hypotensive episode or need for therapeutic interventions were less frequent in 1997 (71% versus 61%, p = 0.015). The ICU mortality was similar (53.3% in 1995 versus 47.3% in 1997; p = 0.52) but death rate in 1997, but not in 1995, was significantly less than predicted from SAPS II (47.3% versus 65.6%; p = 0.02). Length of ICU stay was also reduced for survivors in 1997 (p = 0.04). Implementation of practice guidelines for intermittent hemodialysis in ICU patients lessens hemodynamic instability and may improve outcome.

[Orbital complications of sinusitis in adults]. / Complications orbitaires des sinusites de l'adulte.

Orbital complications of sinusitis are rare in adults but delayed diagnosis is vision and life threatening. We report our experience in 6 patients to present clinical history, bacteriology and discuss the modality of treatment. There were 4 young men and 2 women, aged from 16 to 79 years old. Only one patient had an immunocompromised underlying condition (HIV infection). Four patients had preseptal abscesses and three post septal cellulitis or abscess (one patient had preseptal abscess and post septal abscess and hematoma). Two patients had a complete unilateral loss of light perception. Pathogens encountered were Streptococcus species: 4, strict anaerobes: 1, Pseudomonas aeruginosa: 1 (patient with AIDS). Patients recovered from infection with antibiotics in 6 and surgery in 5 but sequellar blindness occurred in 2 patients. Our experience emphasizes the necessity of antibiotic treatment in bacterial sinusitis and importance of early diagnosis and appropriate management of complications.

[Severe community-acquired bacterial pneumonia from Streptococcus pneumonia in HIV-infected patients: epidemiology and prognostic features of mortality]. / Les pneumonies bactériennes communautaires graves à Streptococcus pneumoniae chez les patients infectés par le VIH: épidémiologie et facteurs pronostiques de décès.

In HIV-infected patients, community-acquired pneumonia due to Streptococcus pneumoniae is more common, more often associated with bacteremia, and more likely to recur. The epidemiology of this condition is discussed based on a literature review. Factors predictive of mortality in severe cases managed in intensive care units are analyzed.

Isolated right-sided Bartonella quintana endocarditis in an immunocompetent adult.

Bartonella quintana is a recently recognized cause of culture-negative left-sided endocarditis. We report a case of isolated tricuspid endocarditis caused by B. quintana in a 65-year-old alcoholic man, who also had immune-complex glomerulonephritis. B. quintana was established as the cause of the endocarditis based on serological tests and on failure of extensive efforts to isolate an alternative organism. The patient improved gradually on antibiotic therapy and did not require surgery. To our knowledge, this is the first report of isolated right-sided endocarditis caused by B. quintana. Although uncommon, Bartonella should be considered in patients with isolated right-sided culture-negative endocarditis.

[Bony involvement of the calcaneum in sarcoidosis. A case report]. / Atteinte osseuse du calcanéum au cours de la sarcoïdose. A propos d'un cas.

Bone lesions of sarcoidosis occur in 10 to 15% of the cases, most often involving the extremities. These frequently corticosteroid-dependent lesions worsen the prognosis of the disease. We report a case of sarcoidosis of 14 years duration in a 58-year old woman who presented with a bone lesion strictly localized to the calcaneum. To our knowledge, such lesion has not previously been reported.

Solvation of the left-handed hexamer d(5BrC-G-5BrC-G-5 BrC-G) in crystals grown at two temperatures.

Crystals of the hexadeoxyoligomer d(5BrC-G-5BrC-G-5BrC-G) were grown at different temperatures (5 degrees C, 18 degrees C and 37 degrees C) in the absence of divalent cations. The crystals grown at 5 degrees C did not diffract X-rays, while those grown at 18 degrees C and 37 degrees C did. The oligomer adopts the left-handed ZI conformation in both crystals. The main difference resides in a more extensive hydration shell in the crystal grown at high temperature than in the crystal grown at low temperature. The high-temperature crystal displays a spine of hydration running deep in the minor groove and linking exocyclic O-2 atoms of the pyrimidine rings. In both crystalline forms, a hydrated sodium ion bound to the N-7 of a guanine ring was found. Strings of water molecules bridging phosphate anionic oxygen atoms are found along the backbone. The absolute values of the propeller-twist are also different in both structures although the values of the twist are very similar. The results point to the importance of the crystallization conditions when analysing fine structural details like solvation properties of oligomers.