Nonlinear modeling of growth and study of a new characterization point applied to Timahdit breed sheep under uncertain paternity.

The objectives of this study are to determine which model, among those of Brody, Logistic, Gompertz, Von Bertalanffy and Richards, is the most appropriate to describe the growth of this breed and to choose a point for this model which would be closest to the slaughter weight which have to be used as a selection criterion. Also, in preparation for genetic evaluation under uncertain paternity, Henderson's Average Numerator Relationship Matrix method was used and an R code was developed for the creation of the inverse matrix A which was replaced the pedigree in the animal model. To do this, 64,282 observations corresponding to 12,944 animals, collected between 2009 and 2016, were analyzed. The Von Bertalanffy function had the smallest AIC, BIC, and deviance criteria values, indicating better data representation for both sexes. Considering the average slaughter live weight of 29.4 kg in the study area, the new point of characterization named f(tbm), later than the inflection point of the growth curve, is closer to the commercial target for females intended for regular slaughter supplying butchers and for animals of both sexes intended for religious festivals. Therefore, it would be appropriate to consider this point as a selection criterion for this breed. The developed R code will be integrated into a free R package allowing the estimation of the genetic parameters of the traits of the Von Bertalanffy model.

Anaesthesiologists' clinical judgment accuracy regarding preoperative full stomach: Diagnostic study in urgent surgical adult patients.

BACKGROUND: In urgent situations, preoperative full stomach assessment mostly relies on clinical judgment. Our primary objective was to assess the diagnostic performance of clinical judgment for the preoperative assessment of full stomach in urgent patients compared to gastric point-of-care ultrasound (PoCUS). Our secondary objective was to identify risk factors associated with PoCUS full stomach in urgent patients. METHODS: We led a prospective observational study at our Hospital, between January and July 2016. Adult patients admitted for urgent surgery were eligible. Patients with altered gastric sonoanatomy, interventions reducing stomach content, impossible lateral decubitus were excluded. Clinical judgment and risk factors of full stomach were collected before gastric PoCUS measurements. Ultrasonographic full stomach was defined by solid contents or liquid volume ≥ 1.5 ml kg-1. Diagnostic performance was assessed through sensitivity, specificity, accuracy, positive and negative predictive value. RESULTS: The prevalence of clinical and PoCUS full stomach in 196 included patients was 29% and 27%, respectively. Positive and negative predictive values were 42% (95% CI: 32.3-52.6%) and 79% (95% CI: 74.9-83.4%), respectively. Patients with PoCUS full stomach were clinically misdiagnosed in 55% of cases. PoCUS full stomach was associated with abdominal or gynaecological-obstetrical surgery (OR 3.6, 95% CI: 1.5-8.8, P < 0.01) but not with fasting durations. Positive solid intake after illness onset with respect to 6-h solid fasting rule was associated with PoCUS low-risk gastric content (OR 0.4, 95% CI: 0.2-0.9, P = 0.03). CONCLUSIONS: Clinical judgment showed poor-to-moderate performance in urgent surgical patients for the diagnosis of full stomach. Gastric PoCUS should be used to assess risk of full stomach in this population.

Diagnostic accuracy of a revised computed tomography angiography score for brain death confirmation, combining supra-tentorial arteries and infra-tentorial veins.

PURPOSE: The 4-point score is the corner stone of brain death (BD) confirmation using computed tomography angiography (CTA). We hypothesized that considering the superior petrosal veins (SPVs) may improve CTA diagnosis performance in BD setting. We aimed at comparing the diagnosis performance of three revised CTA scores including SPVs and the 4-point score in the confirmation of BD. METHODS: In this retrospective study, 69 consecutive adult-patients admitted in a French University Hospital meeting clinical brain death criteria and receiving at least one CTA were included. CTA images were reviewed by two blinded neuroradiologists. A first analysis compared the 4-point score, considered as the reference and three non-opacification scores: a "Toulouse score" including SPVs and middle cerebral arteries, a "venous score" including SPVs and internal cerebral veins and a "7-score" including all these vessels and the basilar artery. Psychometric tools, observer agreement and misclassification rates were assessed. A second analysis considered clinical examination as the reference. RESULTS: Brain death was confirmed by the 4-score in 59 cases (89.4 %). When compared to the 4-score, the Toulouse score displayed a 100 % positive predictive value, a substantial observer agreement (0.77 [0.53; 1]) and the least misclassification rate (3.03 %). Results were similar in the craniectomy subgroup. The Toulouse score was the only revised test that combined a sensitivity close to that of the 4-score (86.4 % [75.7; 93.6] and 89.4 % [79.4; 95.6], p-value < 0.001, respectively) and a substantial observer agreement. CONCLUSIONS: A score including SPVs and middle cerebral arteries is a valid method for BD confirmation using CTA even in patients receiving craniectomy.

Prediction Score for Postoperative Neurologic Complications after Brain Tumor Craniotomy: A Multicenter Observational Study.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Craniotomy for brain tumor displays significant morbidity and mortality, and no score is available to discriminate high-risk patients. Our objective was to validate a prediction score for postoperative neurosurgical complications in this setting. METHODS: Creation of a score in a learning cohort from a prospective specific database of 1,094 patients undergoing elective brain tumor craniotomy in one center from 2008 to 2012. The validation cohort was validated in a prospective multicenter independent cohort of 830 patients from 2013 to 2015 in six university hospitals in France. The primary outcome variable was postoperative neurologic complications requiring in-intensive care unit management (intracranial hypertension, intracranial bleeding, status epilepticus, respiratory failure, impaired consciousness, unexpected motor deficit). The least absolute shrinkage and selection operator method was used for potential risk factor selection with logistic regression. RESULTS: Severe complications occurred in 125 (11.4%) and 90 (10.8%) patients in the learning and validation cohorts, respectively. The independent risk factors for severe complications were related to the patient (Glasgow Coma Score before surgery at or below 14, history of brain tumor surgery), tumor characteristics (greatest diameter, cerebral midline shift at least 3 mm), and perioperative management (transfusion of blood products, maximum and minimal systolic arterial pressure, duration of surgery). The positive predictive value of the score at or below 3% was 12.1%, and the negative predictive value was 100% in the learning cohort. In-intensive care unit mortality was observed in eight (0.7%) and six (0.7%) patients in the learning and validation cohorts, respectively. CONCLUSIONS: The validation of prediction scores is the first step toward on-demand intensive care unit admission. Further research is needed to improve the score's performance before routine use.

Management of severe traumatic brain injury (first 24hours).

The latest French Guidelines for the management in the first 24hours of patients with severe traumatic brain injury (TBI) were published in 1998. Due to recent changes (intracerebral monitoring, cerebral perfusion pressure management, treatment of raised intracranial pressure), an update was required. Our objective has been to specify the significant developments since 1998. These guidelines were conducted by a group of experts for the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie et de réanimation [SFAR]) in partnership with the Association de neuro-anesthésie-réanimation de langue française (ANARLF), The French Society of Emergency Medicine (Société française de médecine d'urgence (SFMU), the Société française de neurochirurgie (SFN), the Groupe francophone de réanimation et d'urgences pédiatriques (GFRUP) and the Association des anesthésistes-réanimateurs pédiatriques d'expression française (ADARPEF). The method used to elaborate these guidelines was the Grade® method. After two Delphi rounds, 32 recommendations were formally developed by the experts focusing on the evaluation the initial severity of traumatic brain injury, the modalities of prehospital management, imaging strategies, indications for neurosurgical interventions, sedation and analgesia, indications and modalities of cerebral monitoring, medical management of raised intracranial pressure, management of multiple trauma with severe traumatic brain injury, detection and prevention of post-traumatic epilepsia, biological homeostasis (osmolarity, glycaemia, adrenal axis) and paediatric specificities.

Hypothermia for Neuroprotection in Convulsive Status Epilepticus.

BACKGROUND: Convulsive status epilepticus often results in permanent neurologic impairment. We evaluated the effect of induced hypothermia on neurologic outcomes in patients with convulsive status epilepticus. METHODS: In a multicenter trial, we randomly assigned 270 critically ill patients with convulsive status epilepticus who were receiving mechanical ventilation to hypothermia (32 to 34°C for 24 hours) in addition to standard care or to standard care alone; 268 patients were included in the analysis. The primary outcome was a good functional outcome at 90 days, defined as a Glasgow Outcome Scale (GOS) score of 5 (range, 1 to 5, with 1 representing death and 5 representing no or minimal neurologic deficit). The main secondary outcomes were mortality at 90 days, progression to electroencephalographically (EEG) confirmed status epilepticus, refractory status epilepticus on day 1, "super-refractory" status epilepticus (resistant to general anesthesia), and functional sequelae on day 90. RESULTS: A GOS score of 5 occurred in 67 of 138 patients (49%) in the hypothermia group and in 56 of 130 (43%) in the control group (adjusted common odds ratio, 1.22; 95% confidence interval [CI], 0.75 to 1.99; P=0.43). The rate of progression to EEG-confirmed status epilepticus on the first day was lower in the hypothermia group than in the control group (11% vs. 22%; odds ratio, 0.40; 95% CI, 0.20 to 0.79; P=0.009), but there were no significant differences between groups in the other secondary outcomes. Adverse events were more frequent in the hypothermia group than in the control group. CONCLUSIONS: In this trial, induced hypothermia added to standard care was not associated with significantly better 90-day outcomes than standard care alone in patients with convulsive status epilepticus. (Funded by the French Ministry of Health; HYBERNATUS ClinicalTrials.gov number, NCT01359332 .).

The optimal time between clinical brain death diagnosis and confirmation using CT angiography: a retrospective study.

BACKGROUND: In several countries, a computed tomography angiography (CTA) is used to confirm brain death (BD). A six­hour interval is recommended between clinical diagnosis and CTA acquisition despite the lack of strong evidence to support this interval. The aim of this study was to determine the optimal timing for CTA in the confirmation of BD. METHODS: This retrospective observational study enrolled all adult patients admitted between January 2009 and December 2013 to the intensive care units of a French university hospital with clinically diagnosed BD and at least one CTA performed as a confirmatory test. The CTAs were identified as conclusive (e.g. yielding confirmation of BD) or inconclusive (e.g. showing persistent brain circulation). RESULTS: One hundred and four patients (sex ratio M/F 1.8; age 55 years [41­64]) underwent 117 CTAs. CTAs confirmed cerebral circulatory arrest in 94 cases yielding a sensitivity of 80%. Inconclusive CTAs were performed earlier than conclusive ones (2 hours [1­3] vs. 4 hours [2­9], P=0.03) and were associated with decompressive craniectomy (5 cases [23%] vs. 6 cases [7%], P=0.05) and the failure to complete full neurological examination (5 cases [23%] vs. 4 cases [5%], P=0.02). Six hours after BD clinical diagnosis, the proportion of conclusive CTA was only 51%, with progressive increase overtime with more than 80% of conclusive CTA after 12 hours. CONCLUSIONS: A 12­hour interval might be appropriate in order to limit the risk of inconclusive CTAs.

Successful treatment of inverted Takotsubo cardiomyopathy after severe traumatic brain injury with milrinone after dobutamine failure.

BACKGROUND: Takotsubo cardiomyopathy can occur at the early phase of severe acute brain injuries. In the case of cardiac output decrease or shock, the optimal treatment is still a matter of debate. Due to massive stress hormone release, the infusion of catecholamines may have limited effects and may even aggravate cardiac failure. Other inotropic agents may be an option. Levosimendan has been shown to have potential beneficial effects in this setting, although milrinone has not been studied. METHODS: We report a case of a young female presenting with inverted Takotsubo cardiomyopathy syndrome after severe traumatic brain injury. RESULTS: Due to hemodynamic instability and increasing levels of infused norepinephrine, dobutamine infusion was begun but rapidly stopped due to tachyarrhythmia. Milrinone infusion stabilized the patient's hemodynamic status and improved cardiac output without deleterious effects. CONCLUSION: Milrinone could be a good alternative when inotropes are required in Takotsubo cardiomyopathy and when dobutamine infusion is associated with tachyarrhythmia.

Assessment of brain midline shift using sonography in neurosurgical ICU patients.

INTRODUCTION: Brain midline shift (MLS) is a life-threatening condition that requires urgent diagnosis and treatment. We aimed to validate bedside assessment of MLS with Transcranial Sonography (TCS) in neurosurgical ICU patients by comparing it to CT. METHODS: In this prospective single centre study, patients who underwent a head CT were included and a concomitant TCS performed. TCS MLS was determined by measuring the difference between the distance from skull to the third ventricle on both sides, using a 2 to 4 MHz probe through the temporal window. CT MLS was measured as the difference between the ideal midline and the septum pellucidum. A significant MLS was defined on head CT as > 0.5 cm. RESULTS: A total of 52 neurosurgical ICU patients were included. The MLS (mean ± SD) was 0.32 ± 0.36 cm using TCS and 0.47 ± 0.67 cm using CT. The Pearson's correlation coefficient (r(2)) between TCS and CT scan was 0.65 (P < 0.001). The bias was 0.09 cm and the limits of agreements were 1.10 and -0.92 cm. The area under the ROC curve for detecting a significant MLS with TCS was 0.86 (95% CI = 0.74 to 0.94), and, using 0.35 cm as a cut-off, the sensitivity was 84.2%, the specificity 84.8% and the positive likelihood ratio was 5.56. CONCLUSIONS: This study suggests that TCS could detect MLS with reasonable accuracy in neurosurgical ICU patients and that it could serve as a bedside tool to facilitate early diagnosis and treatment for patients with a significant intracranial mass effect.

The dairy chains in North Africa (Algeria, Morocco and Tunisia): from self sufficiency options to food dependency?

The Maghreb countries (Algeria, Morocco and Tunisia) have experienced since the early 1950s a rapid demographic growth coupled to a significant rhythm of urbanization. This has led to a marked increase in the demand of dairy products. In order to secure the supply, specific policies have been implemented. They mainly consisted in the establishment of a dairy industry, based on the processing of either raw milk produced locally (in Morocco and Tunisia) or imported milk powder (in Algeria). These divergent options have had significant consequences on the whole organization of the dairy chains in these countries, from cattle rearing practices, to milk collection and processing. They have also implied differences in milk and its derivatives' prices and levels of consumption. The paper draws a comparative analysis of milk chains within the three countries: a supply mainly based on imports in Algeria, whereas in Morocco and Tunisia, the demand is satisfied by a chain relying on locally produced cattle milk. The paper also emphasizes on the future challenges that will have to be addressed: a rising volatility of milk and other strategic inputs' prices (feed, machinery, cattle, etc.) in global markets, an improvement in consumers' awareness about milk quality, a further pressure on natural resources (mainly soils and water) to get more raw milk, in countries already suffering an acute water stress. The article also establishes recommendations about specific issues related to the development of the dairy chains in the context of North Africa. These are mainly linked to the fragmented offer induced by numerous smallholder farms, which implies obvious difficulties to assess the hygienic and the chemical quality of milk batches delivered daily. Moreover, this fragmented offer also means that specific support programs will have to be designed, as the vast majority of farms are not dairy specialized, expecting both milk and calf crop from their herds.

Lethal hemorrhagic alveolitis after adenovirus pneumonia in a lung transplant recipient.

Viral infections are frequent and severe in lung transplant recipients. They frequently occur during the first year after transplantation. We report on a rare case of bilateral adenovirus necrotizing pneumonia with a diffuse alveolar hemorrhage, 4 years after bilateral lung transplantation. The medical evolution was lethal in 72 hours because of respiratory, renal, and cardiac failure. Considering this case and the growing evidence on the severity of adenoviral infections, we call for controlled studies and therapeutic recommendations.

Supporting small-scale dairy farmers in increasing milk production: evidence from Morocco.

This study aimed to evaluate the effects of technical support provided to five small-scale cattle farms in the Tadla irrigation scheme (Morocco) on their milk yield. The first stage consisted of assessing the initial management of dairy herds, especially feeding strategies, and their effects on milk output. This diagnosis revealed major gaps between the existing and the potential milk yield, due to insufficient and imbalanced dietary rations. Based on this diagnosis, technical support was adapted to the reality of each farm by regularly adjusting the dietary rations to the production potential of lactating cows using available feed resources. The production potential of either pure Holstein or crossbred cows was based on the herd's physiological status and its genetic merit. Results showed that milk production could be rapidly improved by balanced dietary rations that enabled the average milk yield of lactating cows to be reached, while optimising feed costs and reducing the cost of milk production. Providing technical support to dairy farms should have a significant impact on overall milk production at different scales (irrigation scheme, plant supply area, national production) while alleviating the poverty of small-scale farmers. It would require the involvement of farmers' organisations such as milk collection co-operatives to replace services provided by the State, which is currently withdrawing from extension activities.

A comparison of dairy cattle systems in an irrigated perimeter and in a suburban region: case study from Morocco.

Multivariate analyses were used to compare dairy production practices and their consequences on milk yield and profitability in cattle farms from two representative regions of Morocco. A regular follow-up of 118 farms (48 in the Rabat-Salé suburban belt and 70 in the Gharb irrigated perimeter) was undertaken to obtain accurate data. Results show significant differences between the two regions. Intensive milk production was more frequent in the suburban zone (more concentrates and better annual milk yield per cow). When conducting a "within-region" principal components analysis, farms' discrimination appeared to take into account all management variables (feeding, cattle sales, profitability), with no reference to farms' structural parameters (arable land and number of cattle). A typology of farms was then established using cluster analysis, with 4 distinct groups, namely: a) concentrates wasters, b) farms with a relatively important milk yield per cow, c) deficit dairy farms and d) beef oriented farms. The last group included almost exclusively farms from the irrigated perimeter (5 out of 7). These results indicate that dairy production promotion in Morocco requires more than just the intensification of forage production, but should focus also on improving management practices. The extension of complete and balanced dairy rations is urgently needed to enhance milk yield and profitability.