Prospective Study of Ultrasound Markers of Organ Congestion in Critically Ill Patients With Acute Kidney Injury.

Introduction: Organ congestion may be a mediator of adverse outcomes in critically ill patients with severe acute kidney injury (AKI). The presence of abnormal venous Doppler waveforms could identify patients with clinically significant organ congestion who may benefit from a decongestive strategy. Methods: This prospective multicenter cohort study enrolled patients with severe AKI defined as Kidney Disease: Improving Global Outcomes stage 2 or higher. Patients were not eligible if they received renal replacement therapy (RRT) for more than 72 hours at the time of screening. Participants underwent serial Doppler ultrasound examinations of the portal, hepatic and intrarenal veins during the week following enrolment. We calculated the venous excess ultrasound (VExUS) score based on these data. The primary outcome studied was major adverse kidney events at 30 days (MAKE30) defined as death, RRT dependence, or a persistent decrease in kidney function. Results: A total of 125 patients were included for whom 291 ultrasound assessments were performed. Severely abnormal venous waveforms were documented in 14.4% of portal vein assessments, 6.5% of intrarenal venous assessments, and 14.4% of hepatic vein assessments. The individual ultrasound markers were not associated with MAKE30. The VExUS score (grade 0-1: reference; grade 2: adjusted hazard ratio [aHR]: 4.03, confidence interval [CI]: 1.81-8.99; grade 3: aHR: 2.70, CI: 1.10-6.65; P = 0.03), as well as severely abnormal portal, hepatic and intrarenal vein Doppler were each independently associated with mortality. Conclusion: Although not significantly associated with MAKE30, venous Doppler abnormalities suggestive of venous congestion were associated with higher mortality in critically ill patients with severe AKI.

Perioperative Quality Initiative (POQI) consensus statement on perioperative assessment of right ventricular function.

BACKGROUND: The right ventricle (RV) plays a central  role in the maintenance of effective cardiac pump function. Despite overwhelming evidence that perioperative RV dysfunction (RVD) and failure (RVF) are associated with poor clinical outcomes, there are very few published recommendations or guidelines for comprehensive, evidence-based RV assessment on the risk of developing either during the perioperative period. MAIN TEXT: To address this gap, the Perioperative Quality Initiative-IX (POQI-IX) investigators group, comprised of clinical experts in anesthesiology, cardiovascular surgery, internal medicine, critical care medicine, and advanced practice nursing, has developed a consensus statement based on current literature, published society recommendations, and the clinical expertise of the group. Herein, the group provides recommendations and evidence-based tools related to perioperative RV assessment, functional screening, staging, and the clinical implications of each. These assessment tools are based on comprehensive patient evaluation consisting of physical examination, biomarker data, imaging, and hemodynamic assessment. CONCLUSION: This review presents a comprehensive tool for assessing perioperative RV function. We hope that this simple, intuitive tool can be applied to all phases of perioperative care and thereby improve patient outcomes.

Venous Doppler to Assess Congestion: A Comprehensive Review of Current Evidence and Nomenclature.

Organ congestion from venous hypertension is an important pathophysiological mechanism mediating organ injury in several clinical contexts including critical illness, congestive heart failure and end-stage chronic kidney disease. However, the practical evaluation of venous congestion is often challenging at the bedside because of the limitations of traditional methods. Point-of-care ultrasound (POCUS) enables the clinician to assess venous velocity profiles during the cardiac cycle using Doppler modalities. Venous Doppler profile abnormalities at multiple sites are detected when elevated venous pressure results in hemodynamic changes within the systemic venous circulation. The detection of these abnormal Doppler profiles may identify patients with clinically significant systemic venous congestion. These patients have been reported to be at increased risk of medical complications. Improving the evaluation of venous congestion may lead to individualized treatment and improved patient outcomes. In this review, we describe the physiologic principles necessary to understand venous Doppler assessment. We also propose a nomenclature for the description of venous Doppler profiles. Finally, we provide a narrative review of the current clinical evidence related to use of venous Doppler assessment in various clinical contexts.

Emerging Applications of Extracardiac Ultrasound in Critically Ill Cardiac Patients.

Point-of-care ultrasound has evolved as an invaluable diagnostic modality and procedural guidance tool in the care of critically ill cardiac patients. Beyond focused cardiac ultrasound, additional extracardiac ultrasound modalities may provide important information at the bedside. In addition to new uses of existing modalities, such as pulsed-wave Doppler ultrasound, the development of new applications is fostered by the implementation of additional features in mid-range ultrasound machines commonly acquired for intensive care units, such as tissue elastography, speckle tracking, and contrast-enhanced ultrasound quantification software. This review explores several areas in which ultrasound imaging technology may transform care in the future. First, we review how lung ultrasound in mechanically ventilated patients can enable the personalization of ventilator parameters and help to liberate them from mechanical ventilation. Second, we review the role of venous Doppler in the assessment of organ congestion and how tissue elastography may complement this application. Finally, we explore how contrast-enhanced ultrasound could be used to assess changes in organ perfusion.

Association between supportive interventions and healthcare utilization and outcomes in patients on long-term prescribed opioid therapy presenting to acute healthcare settings: a systematic review and meta-analysis.

BACKGROUND: Long-term prescription of opioids by healthcare professionals has been linked to poor individual patient outcomes and high resource utilization. Supportive strategies in this population regarding acute healthcare settings may have substantial impact. METHODS: We performed a systematic review and meta-analysis of primary studies. The studies were included according to the following criteria: 1) age 18 and older; 2) long-term prescribed opioid therapy; 3) acute healthcare setting presentation from a complication of opioid therapy; 4) evaluating a supportive strategy; 5) comparing the effectiveness of different interventions; 6) addressing patient or healthcare related outcomes. We performed a qualitative analysis of supportive strategies identified. We pooled patient and system related outcome data for each supportive strategy. RESULTS: A total of 5664 studies were screened and 19 studies were included. A total of 9 broad categories of supportive strategies were identified. Meta-analysis was performed for the "supports for patients in pain" supportive strategy on two system-related outcomes using a ratio of means. The number of emergency department (ED) visits were significantly reduced for cohort studies (n = 6, 0.36, 95% CI [0.20-0.62], I2 = 87%) and randomized controlled trials (RCTs) (n = 3, 0.71, 95% CI [0.61-0.82], I2 = 0%). The number of opioid prescriptions at ED discharge was significantly reduced for RCTs (n = 3, 0.34, 95% CI [0.14-0.82], I2 = 78%). CONCLUSION: For patients presenting to acute healthcare settings with complications related to long-term opioid therapy, the intervention with the most robust data is "supports for patients in pain".

Brain natriuretic peptide to predict successful liberation from mechanical ventilation in critically ill patients: a systematic review and meta-analysis.

BACKGROUND: Predicting successful liberation from mechanical ventilation (MV) in critically ill patients is challenging. Brain natriuretic peptide (BNP) has been proposed to help guide decision-making for readiness to liberate from MV following a spontaneous breathing trial (SBT). METHODS: We performed a systematic review and meta-analysis of randomized and prospective observational studies that measured BNP levels at the time of SBT in patients receiving MV. The primary endpoint was successful liberation from MV (absence of reintubation or non-invasive ventilation at 48 h). Statistical analyses included bi-variate and Moses-Littenberg models and DerSimonian-Laird pooling of areas under ROC curve (AUROC). RESULTS: A total of 731 articles were screened. Eighteen adult and 2 pediatric studies were fulfilled pre-specified eligibility. The measure of the relative variation of BNP during SBT (ΔBNP%) after exclusion of SBT failure by clinical criteria in adults yielded a sensitivity and specificity of 0.889 [0.831-0.929] and 0.828 [0.730-0.896] for successful liberation from MV, respectively, with a pooled AUROC of 0.92 [0.88-0.97]. The pooled AUROC for any method of analysis for absolute variation of BNP (ΔBNP), pre-SBT BNP, and post-SBT BNP were 0.89 [0.83-0.95], 0.77 [0.63-0.91], and 0.85 [0.80-0.90], respectively. CONCLUSION: The relative change in BNP during a SBT has potential value as an incremental tool after successful SBT to predict successful liberation from MV in adults. There is insufficient data to support the use of BNP in children or as an alternate test to clinical indices of SBT, or the use of ΔBNP, BNP-pre, and BNP-post as an alternate or incremental test. TRIAL REGISTRATION: PROSPERO CRD42018087474 (6 February 2018).

Association between harm reduction strategies and healthcare utilization in patients on long-term prescribed opioid therapy presenting to acute healthcare settings: a protocol for a systematic review and meta-analysis.

INTRODUCTION: Opioids are routinely used to treat a variety of chronic conditions associated with pain. However, they are a class of medications with a significant potential for adverse health effects, with and without misuse. Opioid misuse, as defined as inappropriate use of appropriately prescribed opioids, is becoming more well-recognized publicly but does not have clear treatment options. Opioid misuse has been linked to variety of poor outcomes and its consequences have a significant impact on healthcare resource utilization. The evidence on harm reduction strategies to mitigate adverse events prompting presentation to acute care settings for patients presenting with long-term opioid use is sparse. METHODS AND ANALYSIS: We will perform a systematic review and meta-analysis to catalog effective harm reduction strategies and identify the most effective ones to reduce avoidable healthcare utilization in patients on long-term opioid therapy who present to acute health care settings with complications attributed to opioid misuse. A search strategy will be developed and executed by an information specialist; electronic databases (MEDLINE, EMBASE, CINAHL, Cochrane Library) and additional sources will be searched. Search themes will include opioids, chronic drug use, and acute healthcare settings. Citation screening, selection, quality assessment, and data abstraction will be performed in duplicate. A comprehensive inventory of harm reduction strategies will be developed. Data will be collected on patient-related outcomes associated with each identified harm reduction strategy. When sufficiently homogeneous data on interventions, population, and outcomes is available, it will be pooled for aggregate analysis. Evaluation of the methodological quality of individual studies and of the quality of the body of evidence will be performed. Our primary objective will be to identify harm reduction strategies that have been shown to result in clinically relevant and statistically significant improvements in patient outcomes and/or decreased healthcare utilization. DISCUSSION: This study will better characterize harm reduction strategies for patients on long-term prescribed opioids presenting to acute healthcare settings. It will also add new knowledge and generate greater understanding of key knowledge gaps of the long-term prescribed opioid use and its impact on healthcare utilization. SYSTEMATIC REVIEW REGISTRATION: CRD42018088962 .

Brain natriuretic peptide to predict successful liberation from mechanical ventilation in critically ill patients: protocol for a systematic review and meta-analysis.

INTRODUCTION: Predicting successful liberation from mechanical ventilation (MV) among critically ill patients receiving MV can be challenging. The current parameters used to predict successful extubation have shown variable predictive value. Brain natriuretic peptide (BNP) has been proposed as a novel biomarker to help guide decision-making in readiness for liberation of MV following a spontaneous breathing trial (SBT). Current evidence on the predictive ability of BNP has been uncertain, and BNP has not been integrated into clinical practice guidelines. METHODS AND ANALYSIS: We will perform a systematic review and meta-analysis to evaluate the value of BNP during SBT to predict success of liberation from MV. A search strategy will be developed in collaboration with a research librarian, and electronic databases (MEDLINE, EMBASE, Cochrane Library, Web of Science) and additional sources will be searched. Search themes will include: (1) BNP and (2) weaning, extubation and/or liberation from MV. Citation screening, selection, quality assessment and data abstraction will be performed in duplicate. The primary outcome will be liberation from MV; secondary outcomes will include time to reintubation, mortality, MV duration, total and postextubation intensive care unit (ICU) stay, hospitalisation duration, tracheostomy rate, ICU-acquired weakness rate and ventilator-free days. Primary statistical analysis will include predictive value of BNP by receiver operating characteristic curve, sensitivity/specificity and likelihood ratios for combination of BNP and SBT parameters for failure of liberation from MV. Secondary statistical analysis will be performed on individual and combinations of extracted metrics. ETHICS AND DISSEMINATION: Our review will add knowledge by mapping the current body of evidence on the value of BNP testing for prediction of successful liberation from MV, and describe knowledge gaps and research priorities. Our findings will be disseminated through peer-reviewed publication, presentation at a scientific congress, through regional/national organisations and social media. Research ethics approval is not required. PROSPERO REGISTRATION NUMBER: CRD42018087474.

[Chronic diseases and precarity: obstacles to management and recommendations]. / Maladies chroniques et précarité : obstacles à la prise en charge et préconisations.

A study was conducted in the Lorraine region concerning the difficulties encountered in the management of chronic diseases in patients in a situation of precarity based on interviews of the patients concerned and general practitioners. Numerous difficulties as well as several facilitating factors were identified. The elements reported by patients and doctors frequently converged: the importance of living conditions, the frequently pejorative attitudes of doctors, administrative complexities. The doctor-patient relationship is the cornerstone of facilitating factors. Patients attach considerable importance to the relationship of confidence developed with their attending physician. They want their doctor to use simple words and avoid making them feel guilty, allowing them to enter into a real healthcare partnership in which they can actively participate in decisions concerning them. On the basis ofthesefindings, thestudy formulated recommendations for improvement of management, essentially concerning administrative measures of social protection and access to care.

Ultrasonic transducers based on undoped lead-free (K0.5Na0.5)NbO3 ceramics.

Lead zirconate titanate (PZT) ceramics are the dominant piezoelectric elements for non-destructive evaluation (NDE) and ultrasonic transducers devices. However, the presence of lead content may impose the scientific community to develop lead-free ceramics, concerning human health and environmental safety. During the past ten years, many contributions have highlighted the potential properties of complex compositions like LiNbO3, LiTaO3 and LiSbO3 in the lead-free (K0.5Na0.5)NbO3 KNN system. In this context, for the first time, the practical applications and the effectiveness of simply undoped (K0.5Na0.5)NbO3 (KNN) ceramics are investigated. KNN powder is prepared by conventional solid state mixed oxide route. Ceramics of this material are prepared using conventional sintering (CS) and spark plasma sintering (SPS). Thickness coupling factor kt of 44-46%, planar coupling factor kp of 29-45%, relative permittivity at constant strain ε33,r(S) of 125-243 and acoustic impedance Z of 23-30 MRay are obtained for these two kinds of undoped KNN ceramics. Both ceramics are used to build single-element ultrasonic transducers. Relative bandwidth of 49-78% and insertion loss of -27 and -51dB are obtained for SPS and CS transducers, respectively. These results are suitable for use in non-destructive evaluation. The effectiveness of undoped KNN is evaluated using the KLM model, and compared to standard PZT based probe. Finally, chemical aging test of undoped KNN has demonstrated its stability in water.

[The ethical dimensions of health education, or the limits of beneficence]. / Aspects ethiques de l'education pour la sant... ou les limites de la bienfaisance.

Ethical issues have only recently emerged as a topic of debate in health education. Until recently, health education was seen as "beneficent" by nature and as designed to improve well-being and quality of life. Traditionally, the purpose of health education was to promote behavior change. The idea of intruding into people's private lives raises the question of the objectives and methods of health education. The principles underlying ethical reflection--beneficence, non-malfeasance, autonomy and social justice--provide a basis for identifying a number of problems or abuses. Traditionally, people have tended to be seen as implicitly responsible for their own behavior, a view based on a moralistic, guilt-inducing and didactic approach to health and health behavior. The assumption is that these infringements affect the identity and dignity of persons. In addition, imposing standards and norms of behavior defined by others amounts to undermining or denying the autonomy of individuals. Finally, traditional health education approaches, and in particular communication campaigns, may contribute to the improvement of health, but it is at the cost of increased inequalities. To conclude, ethics is both a statement of values and a method or process. Ethics needs to be debated and discussed in a democratic forum. It is up to citizens, not experts, to establish the link between means and ends. Health promotion has resulted in a shift in perspective--a shift that has provided protection against ethical lapses and violations. This paper argues that health education must create the conditions of autonomy by focusing first on environmental factors and inequalities.

A preliminary investigation of farm-level risk factors for cattle condemnation at the slaughterhouse: a case-control study on French farms.

The financial impact of condemnation for farmers and the importance of efficiency in the meat inspection process to guarantee food safety are well known. Identifying farm-level risk factors for condemnation are useful in order to find a way for farmers to potentially reduce their condemnation rates and to build a risk-based farm classification for veterinary services to target both meat inspection and farms inspections. To our knowledge, this has not yet been done, probably due to a lack of available meat inspection data. A preliminary investigation was performed through a case-control study on 36 French farms, from a dairy production region to identify farm-level risk factors for high condemnation rates (i.e. more than 45% of cattle with at least one portion of the carcass condemned). Multivariable exact logistic regression was performed to take into account the small sample size. The final model identified two significant risk factors. The odds of having a high condemnation rate was at least twice as greater for farmers who did not adhere to the quality charter of an international retailer and was significantly higher when the most qualified worker on the farm had a degree in agriculture. This latter effect was unexpected and is reviewed in the discussion section. The protective effect of the quality charter could be explained by the annual control of farms performed to guarantee compliance with good farming practices in the adhering farms. It led us to believe that compliance with well known good farming practices could be a way for farmers to reduce their condemnation rates. This study is a preliminary investigation performed on a small sample size of farms that were mainly dairy farms. It is a first step for further investigations that need to be done on this topic at a larger scale to fill the current lack of knowledge.