[Embolization of splenic artery aneurysms: Treatment of choice. About a case and review of the literature]. / Embolisation des anévrysmes de l'artère splénique : traitement de choix. À propos d'un cas et revue de la littérature.

Splenic artery aneurysms constitute 60% of digestive artery aneurysms. They are often discovered incidentally and by imaging. Currently, endovascular treatment is considered the first-line treatment, as it is less invasive with less morbidity and mortality than surgery. An aggressive approach in their management is certainly justified because the overall mortality of ruptured splenic aneurysms is 25%. False splenic aneurysms have a greater potential for rupture than true aneurysms because they grow faster. Endovascular treatment is generally indicated for aneurysms larger than 2cm or with an increase in size of more than 0.5cm/year. Embolization is rarely associated with an infarction of the spleen due to the good supply of short gastric vessels. Embolization is performed using different materials including coils, which can be used alone or with other embolic agents. Post-embolization syndrome can be seen with persistent pain, fever and other systemic symptoms. Endovascular treatment compared to open surgery is associated with better quality of life and appears to be the most cost-effective strategy. Endovascular treatment and especially coil embolization are starting to be the standard treatment. Surgical and laparoscopic treatment are reserved for ruptured aneurysms which are burdened with significant mortality, especially in pregnant women. We report the case of a 66-year-old female patient in whom a splenic artery aneurysm was discovered incidentally during an ultrasound for an ovarian cyst.

Neuroergonomic and psychometric evaluation of full-face crew oxygen masks respiratory tolerance: a proof-of-concept study.

INTRODUCTION: Preventing in-flight hypoxia in pilots is typically achieved by wearing oxygen masks. These masks must be as comfortable as possible to allow prolonged and repeated use. The consequences of mask-induced facial contact pressure have been extensively studied, but little is known about mask-induced breathing discomfort. Because breathlessness is a strong distractor and engages cerebral resources, it could negatively impact flying performances. METHODS: Seventeen volunteers (age 20-32) rated respiratory discomfort while breathing with no mask and with two models of quick-donning full-face crew oxygen masks with regulators (mask A, mask B). Electroencephalographic recordings were performed to detect a putative respiratory-related cortical activation in response to inspiratory constraint (experiment 1, n=10). Oxygen consumption was measured using indirect calorimetry (experiment 2, n=10). RESULTS: With mask B, mild respiratory discomfort was reported significantly more frequently than with no mask or mask A (experiment 1: median respiratory discomfort on visual analogue scale 0.9 cm (0.5-1.4), experiment 1; experiment 2: 2 cm (1.7-2.9)). Respiratory-related cortical activation was present in 1/10 subjects with no mask, 1/10 with mask A and 6/10 with mask B (significantly more frequently with mask B). Breathing pattern, sigh frequency and oxygen consumption were not different. CONCLUSIONS: In a laboratory setting, breathing through high-end aeronautical full-face crew oxygen masks can induce mild breathing discomfort and activate respiratory-related cortical networks. Whether or not this can occur in real-life conditions and have operational consequences remains to be investigated. Meanwhile, respiratory psychometric and neuroergonomic approaches could be worth integrating to masks development and evaluation processes.

CARE-rCortex: A Matlab toolbox for the analysis of CArdio-REspiratory-related activity in the Cortex.

BACKGROUND: Although cardio-respiratory (CR) system is generally controlled by the autonomic nervous system, interactions between the cortex and these primary functions are receiving an increasing interest in neurosciences. NEW METHOD: In general, the timing of such internally paced events (e.g. heartbeats or respiratory cycles) may display a large variability. For the analysis of such CR event-related EEG potentials, a baseline must be correctly associated to each cycle of detected events. The open-source toolbox CARE-rCortex provides an easy-to-use interface to detect CR events, define baselines, and analyse in time-frequency (TF) domain the CR-based EEG potentials. RESULTS: CARE-rCortex provides some practical tools to detect and validate these CR events. Users can define baselines time-locked to a phase of respiratory or heart cycle. A statistical test has also been integrated to highlight significant points of the TF maps with respect to the baseline. We illustrate the use of CARE-rCortex with the analysis of two real cardio-respiratory datasets. COMPARISON WITH EXISTING METHODS: Compared to other open-source toolboxes, CARE-rCortex allows users to automatically detect CR events, to define and check baselines for each detected event. Different baseline normalizations can be used in the TF analysis of EEG epochs. CONCLUSIONS: The analysis of CR-related EEG activities could provide valuable information about cognitive or pathological brain states. CARE-rCortex runs in Matlab as a plug-in of the EEGLAB software, and it is publicly available at https://github.com/FannyGrosselin/CARE-rCortex.

How useful are hemoglobin concentration and its variations to predict significant hemorrhage in the early phase of trauma? A multicentric cohort study.

BACKGROUND: The diagnostic value of hemoglobin (Hb) for detecting a significant hemorrhage (SH) in the early phase of trauma remains controversial. The present study aimed to assess the abilities of Hb measurements taken at different times throughout trauma management to identify patients with SH. METHODS: All consecutive adult trauma patients directly admitted to six French level-1 trauma centers with at least one prehospital Hb measurement were analyzed. The abilities of the following variables to identify SH (≥ 4 units of red blood cells in the first 6 h and/or death related to uncontrolled bleeding within 24 h) were determined and compared to that of shock index (SI): Hb as measured with a point-of-care (POC) device by the prehospital team on scene (POC-Hbprehosp) and upon patient's admission to the hospital (POC-Hbhosp), the difference between POC-Hbhosp and POC-Hbprehosp (DeltaPOC-Hb) and Hb as measured by the hospital laboratory on admission (Hb-Labhosp). RESULTS: A total of 6402 patients were included, 755 with SH and 5647 controls (CL). POC-Hbprehosp significantly predicted SH with an area under ROC curve (AUC) of 0.72 and best cutoff values of 12 g/dl for women and 13 g/dl for men. POC-Hbprehosp < 12 g/dl had 90% specificity to predict of SH. POC-Hbhosp and Hb-Labhosp (AUCs of 0.92 and 0.89, respectively) predicted SH better than SI (AUC = 0.77, p < 0.001); best cutoff values of POC-Hbhosp were 10 g/dl for women and 12 g/dl for men. DeltaPOC-Hb also predicted SH with an AUC of 0.77, a best cutoff value of - 2 g/dl irrespective of the gender. For a same prehospital fluid volume infused, DeltaPOC-Hb was significantly larger in patients with significant hemorrhage than in controls. CONCLUSIONS: Challenging the classical idea that early Hb measurement is not meaningful in predicting SH, POC-Hbprehosp was able, albeit modestly, to predict significant hemorrhage. POC-Hbhosp had a greater ability to predict SH when compared to shock index. For a given prehospital fluid volume infused, the magnitude of the Hb drop was significantly higher in patients with significant hemorrhage than in controls.

Effect of early use of noradrenaline on in-hospital mortality in haemorrhagic shock after major trauma: a propensity-score analysis.

BACKGROUND: The role of vasopressors in trauma-related haemorrhagic shock (HS) remains a matter of debate. They are part of the most recent European recommendations on the management of HS and are regularly used in France. We assessed the effect of early administration of noradrenaline in 24 h mortality of trauma patients in HS, using a propensity-score analysis. METHODS: The study included patients from a multicentre prospective regional trauma registry. HS was defined as transfusion of ≥4 erythrocyte-concentrate units during the first 6 h. Patients with a Glasgow coma scale=3 and pre-hospital traumatic cardiac arrest were excluded. The main outcome measure was in-hospital mortality. The explicative and adjustment variables for the outcome and treatment allocation were predetermined by a Delphi method. The in-hospital mortality of patients with and without early administration of noradrenaline was compared in a propensity-score model, including all predetermined variables. RESULTS: Of 7141 patients in the registry in the study period, 6353 were screened and 518 patients in HS (201 with early noradrenaline use and 317 without) were included and analysed. After propensity-score matching, 100 patients remained in each group, and the hazard-ratio mortality was 0.95 (95% confidence interval: 0.45-2.01; P=0.69). CONCLUSIONS: The results of the present study suggest that noradrenaline use in the early phase of traumatic HS does not seem to affect mortality adversely. This observation supports a rationale for equipoise in favour of a prospective trial of the use of vasopressors in HS after trauma.

[Medical information system (PMSI) does not adequately identify severe trauma]. / La codification PMSI identifie mal les traumatismes graves.

BACKGROUND: Resource allocation to hospitals is highly dependent on appropriate case coding. For trauma victims, the major diagnosis-coding category (DCC) is multiple trauma (DCC26), which triggers higher funding. We hypothesized that DCC26 has limited capacity for appropriate identification of severe trauma victims. METHODS: We studied Injury Severity Score (ISS), Trauma Related Injury Severity Score (TRISS) and in-hospital mortality using data recorded in three level 1 trauma centers over a 2-year period. Patients were divided into two groups: DCC26 and non-DCC26. For non-DCC26 patients, two subgroups were identified: patients with severe head trauma and patients with spinal trauma. Clinical endpoints were mortality, ISS>15 and TRISS, IGS II. Use of hospital resources was estimated using funding and expenditures associated with each patient. RESULTS: During the study period, 2570 trauma victims were included in the analysis. These patients were 39±18 years old, with median ISS=14, and observed mortality=10 %. Group DCC26 had 811 (31 %) patients, group non-DCC26 1855 (69 %) patients. DCC26 coding identified a more severely injured group of patients. However, in the group non-DCC26, there was a high proportion of severe trauma (ISS>15: 35 %; TRISS<0.95: 9 %). CONCLUSION: DCC26 is not an appropriate coding for severe trauma patients. For these patients, expenditures will include intensive care and rare and costly resources. We propose to take into account the TRISS score to improve trauma coding.

Organization in response to massive afflux of war victims in civilian practice - experimental feedback from the November 2015 Paris terrorist attacks.

The arrival of a large number of war-weapon casualties at a civilian trauma center requires anticipation. A plan defining the management principles and the respective roles of the involved physicians and nurses and their interaction with each other is essential. Uni-directional patient flow associated with adequate numbers of staff physicians and nurses under the leadership of a medical director is essential to prevent the overwhelming of the trauma center. Routine and regular interaction between the pre-hospital medical flow control system and the medical director, on one hand, and between surgical teams and the medical director, on the other, are necessary to know when to apply "damage control" surgical techniques. Based on the feedback of a level 1 trauma center that received 53 victims of the November 13, 2015 terrorist attack in Paris, we present the factors of success, and the stumbling blocks.

Riemannian Geometry Applied to Detection of Respiratory States From EEG Signals: The Basis for a Brain-Ventilator Interface.

GOAL: During mechanical ventilation, patient-ventilator disharmony is frequently observed and may result in increased breathing effort, compromising the patient's comfort and recovery. This circumstance requires clinical intervention and becomes challenging when verbal communication is difficult. In this study, we propose a brain-computer interface (BCI) to automatically and noninvasively detect patient-ventilator disharmony from electroencephalographic (EEG) signals: a brain-ventilator interface (BVI). METHODS: Our framework exploits the cortical activation provoked by the inspiratory compensation when the subject and the ventilator are desynchronized. Use of a one-class approach and Riemannian geometry of EEG covariance matrices allows effective classification of respiratory states. The BVI is validated on nine healthy subjects that performed different respiratory tasks that mimic a patient-ventilator disharmony. RESULTS: Classification performances, in terms of areas under receiver operating characteristic curves, are significantly improved using EEG signals compared to detection based on air flow. Reduction in the number of electrodes that can achieve discrimination can be often desirable (e.g., for portable BCI systems). By using an iterative channel selection technique, the common highest order ranking, we find that a reduced set of electrodes (n = 6) can slightly improve for an intrasubject configuration, and it still provides fairly good performances for a general intersubject setting. CONCLUSION: Results support the discriminant capacity of our approach to identify anomalous respiratory states, by learning from a training set containing only normal respiratory epochs. SIGNIFICANCE: The proposed framework opens the door to BVIs for monitoring patient's breathing comfort and adapting ventilator parameters to patient respiratory needs.

Early Results of Physician Modified Fenestrated Stent Grafts for the Treatment of Thoraco-abdominal Aortic Aneurysms.

OBJECTIVES: The aim was to determine whether physician modified stent grafts (PMSGs) are safe and effective for the treatment of high risk patients with thoraco-abdominal aortic aneurysms (TAAAs). DESIGN: This was a retrospective single institution study. MATERIAL: Consecutive patients with TAAA undergoing endovascular repair using a PMSG between January 2012 and June 2014 were evaluated. METHODS: Fenestrations to preserve branch vessels were created in TX2 thoracic (Cook Medical) stent grafts. Pre- intra- and post-operative data were recorded by means of a prospectively maintained database. RESULTS: Eleven high risk patients with TAAA (type I, n = 4; type III, n = 3; type IV, n = 3; type V, n = 1) underwent fenestrated endovascular repair using PMSGs. Indications were painful aneurysm (n = 5), >70 mm rapidly enlarging aneurysm (n = 4), saccular aneurysm (n = 1), and visceral patch false aneurysm after open repair of a type IV TAAA (n = 1). In four asymptomatic patients, an additional fenestration was created for temporary selective sac perfusion and occluded 2-4 weeks later. Median duration for stent graft modifications was 2 hours (range 1-3 hours). The median number of fenestrations was three (range 2-4). One patient died during the post-operative period from colonic ischemia, giving a 9% in hospital mortality rate. Four (36%) patients presented with moderate to severe complications. One (9%) patient presented with a paraparesis that resolved completely after spinal fluid drainage. Among surviving patients, four required early endovascular re-intervention for type III endoleak (n = 2), type Ia endoleak (n = 1), or target vessel cannulation failure (n = 1). The median follow up time was 6 months (range 3-20 months). During follow up, no other complications occurred and all target vessels remained patent. One patient presented with a persistent type II endoleak. CONCLUSION: PMSGs provided acceptable short-term results and may be a management option for the treatment of TAAA in selected high risk patients. Durability concerns need to be assessed in additional studies with long-term follow up.

Postoperative pulmonary complications updating.

Postoperative pulmonary complications (PPCs) are a major contributor to the overall risk of surgery. PPCs affect the length of hospital stay and are associated with a higher in-hospital mortality. PPCs are even the leading cause of death either in cardiothoracic surgery but also in non-cardiothoracic surgery. Thus, reliable PPCs risk stratification tools are the key issue of clinical decision making in the perioperative period. When the risk is clearly identified related to the patient according the ARISCAT score and/or the type of surgery (mainly thoracic and abdominal), low-cost preemptive interventions improve outcomes and new strategies can be developed to prevent this risk. The EuSOS, PERISCOPE and IMPROVE studies demonstrated this care optimization by risk identification first, then risk stratification and new care (multifaceted) strategies implementation allowing a decrease in PPCs mortality by optimizing the clinical path of the patient and the care resources.

Airway management in obese patient.

Oxygenation maintenance is the cornerstone of airway management in the obese patient related to anatomic and pathophysiologic issues. Difficult mask ventilation (DMV) risk is increased in obese patients according recognized predictors (Body Mass Index [BMI]>26 kg/m2, age >55 years, jaw protrusion severely limited, lack of teeth, snoring, beard, Mallampati class III or IV) and should systematically search. Difficult tracheal intubation (DTI) risk may be increased and risk should be assessed in a careful manner. Increased neck circumference and high BMI (>35 kg/m2) should be added to "standard" preoperative airway assessment including:Mallampati class, mouth opening and thyromental distance. In obese patients, preoxygenation is mandatory by 25° head-up position achieving better gas exchange than in supine position. In addition, to prevent early arterial oxygen desaturation related to a reduced functional residual capacity (FRC), atelectasis formation during anesthetic induction and after tracheal intubation, non invasive positive pressure ventilation and application of PEEP throughout this period are recommended. Airway management in obese patients has to consider: the anesthesia technique with maintenance or not of spontaneous ventilation, the available oxygenation technique in case of anticipated DMV, and the appropriate tracheal intubation technique (fiberoptic intubation technique or videolaryngoscope) according to the patient status and will. In unexpected difficult airway, the very first priority is oxygenation and a predefined strategy has to be implemented with oxygenation devices first (supraglottic devices or ILMA). Lastly, the final step of the obese airway management is tracheal extubation and recovery. A strategy with a fully awake patient, without residual paralysis, and a 25° head-up position is mandatory.

The concept of damage control: extending the paradigm in the prehospital setting.

OBJECTIVE: The purpose of this review is to present the progressive extension of the concept of damage control resuscitation, focusing on the prehospital phase. ARTICLE TYPE: Review of the literature in Medline database over the past 10 years. DATA SOURCE: Medline database looking for articles published in English or in French between April 2002 and March 2013. Keywords used were: damage control resuscitation, trauma damage control, prehospital trauma, damage control surgery. Original articles were firstly selected. Editorials and reviews were secondly studied. DATA SYNTHESIS: The importance of early management of life-threatening injuries and rapid transport to trauma centers has been widely promulgated. Technical progress appears for external methods of hemostasis, with the development of handy tourniquets and hemostatic dressings, making the crucial control of external bleeding more simple, rapid and effective. Hypothermia is independently associated with increased risk of mortality, and appeared accessible to improvement of prehospital care. The impact of excessive fluid resuscitation appears negative. The interest of hypertonic saline is denied. The place of vasopressor such as norepinephrine in the early resuscitation is still under debate. The early use of tranexamic acid is promoted. Specific transfusion strategies are developed in the prehospital setting. CONCLUSION: It is critical that both civilian and military practitioners involved in trauma continue to share experiences and constructive feedback. And it is mandatory now to perform well-designed prospective clinical trials in order to advance the topic.

Severity assessment in trauma patient.

Severity assessment in trauma patients is mandatory. It started during initial phone call that alerts emergency services when a trauma occurred. On-call physician assesses severity based on witness-provided information, to adapt emergency response (paramedics, emergency physicians). Initial severity assessment is subsequently improved based on first-responder provided informations. Whenever information comes, it helps providing adequate therapeutics and orientating the patient to the appropriate hospital. Severity assessment is based upon pre-trauma medical conditions, mechanism of injury, anatomical lesions and their consequences on physiology. Severity information can be summarized using scores, yet those are not used in France, except for post-hoc scientific purposes. Triage is usually performed using algorithms. Whatever the way triage is performed, triage tools are based on mortality as main judgement criterion. Other criteria should be considered, such as therapeutics requirements. The benefit of biomarkers of ultrasonography at prehospital setting remains to be assessed.

Gate-induced transition between metal-type and thermally activated transport in self-catalyzed MBE-grown InAs nanowires.

Electronic transport properties of InAs nanowires are studied systematically. The nanowires are grown by molecular beam epitaxy on a SiOx-covered GaAs wafer, without using foreign catalyst particles. Room-temperature measurements revealed relatively high resistivity and low carrier concentration values, which correlate with the low background doping obtained by our growth method. Transport parameters, such as resistivity, mobility, and carrier concentration, show a relatively large spread that is attributed to variations in surface conditions. For some nanowires the conductivity has a metal-type dependence on temperature, i.e. decreasing with decreasing temperature, while other nanowires show the opposite temperature behavior, i.e. temperature-activated characteristics. An applied gate voltage in a field-effect transistor configuration can switch between the two types of behavior. The effect is explained by the presence of barriers formed by potential fluctuations.

Ventilatory response to exercise does not evidence electroencephalographical respiratory-related activation of the cortical premotor circuitry in healthy humans.

AIM: The neural structures responsible for the coupling between ventilatory control and pulmonary gas exchange during exercise have not been fully identified. Suprapontine mechanisms have been hypothesized but not formally evidenced. Because the involvement of a premotor circuitry in the compensation of inspiratory mechanical loads has recently been described, we looked for its implication in exercise-induced hyperpnea. METHODS: Electroencephalographical recordings were performed to identify inspiratory premotor potentials (iPPM) in eight physically fit normal men during cycling at 40 and 70% of their maximal oxygen consumption ((V)·O(2max) ). Relaxed pedalling (0 W) and voluntary sniff manoeuvres were used as negative and positive controls respectively. RESULTS: Voluntary sniffs were consistently associated with iPPMs. This was also the case with voluntarily augmented breathing at rest (in three subjects tested). During the exercise protocol, no respiratory-related activity was observed whilst performing bouts of relaxed pedalling. Exercise-induced hyperpnea was also not associated with iPPMs, except in one subject. CONCLUSION: We conclude that if there are cortical mechanisms involved in the ventilatory adaptation to exercise in physically fit humans, they are distinct from the premotor mechanisms activated by inspiratory load compensation.

[Acute exacerbation of restless legs syndrome during perioperative procedures: case reports and suggested management]. / Implications anesthésiques du syndrome des jambes sans repos : observations cliniques et recommandations pratiques.

Restless legs syndrome, or Ekbom syndrome, is a common (yet poorly recognized) neurological condition, with sensitive and motor symptoms and a probable genetic vulnerability. The subjects experience an imperious urge to move their legs at rest, possibly associated with paresthesia and pain, which occurs mostly in the evening and night, and is transiently relieved by movements and walking. Severe cases suffer from involuntary leg jerks during quiet wake and severe insomnia. The syndrome is more frequent in middle-aged subjects, in women, and in iron deficient subjects (renal insufficiency, pregnancy, multiparous mothers). We report a series of patients with a severe restless legs syndrome, adequately treated with small doses of dopamine agonist in the evening. They experienced a perioperative, acute exacerbation of their syndrome. The inability to stay still with involuntary jerks in the operating room, the generalized pain followed by suicidal thoughts, and the agitation with akathisia in the recovery room, complicated the surgery procedures and their follow-ups. The prevention of restless legs exacerbation includes: (i) contra-indicating hydroxyzine, droperidol and any other drug blocking the central dopamine transmission before and during anaesthesia; (ii) using intravenous or subcutaneous opioids, and benzodiazepines during and after the surgery procedure; (iii) temporary increasing the dosage of dopamine agents after surgery; (iv) monitoring (and compensating if low) the iron stores after surgery.

[How to succeed at funding a research year in anaesthesiology and critical care in France?]. / Du master au post-doctorat: comment assurer le financement d'une année de recherche en anesthésie-réanimation?

Good research needs good financial support. The research fellowship is a full-time job that leaves no time for another job to pay the rent. Funding the daily-life part of the fellowship is therefore a sine qua none condition for serenity and good research. Preparing grants applications for research is a crucial step towards success. There is however a lack of easily available information for personal funding application in Anesthesiology and Critical Care research. In this review, we aimed to present the different stages of this long process, from grant application to taxes payment.