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Background Fetal radiation exposure in pregnant women with trauma is a concern. The purpose of this study was to evaluate fetal radiation exposure with regard to the type of injury assessment performed. Methods It is a multicentre observational study. The cohort study included all pregnant women suspected of severe traumatic injury in the participating centres of a national trauma research network. The primary outcome was the cumulative radiation dose (mGy) received by the fetus with respect to the type of injury assessment initiated by the physician in charge of the pregnant patient. Secondary outcomes were maternal and fetal morbi-mortality, the incidence of haemorrhagic shock and the physicians’ imaging assessment with consideration of their medical specialty. Results Fifty-four pregnant women were admitted for potential major trauma between September 2011 and December 2019 in the 21 participating centres. The median gestational age was 22 weeks [12–30]. 78% of women (n = 42) underwent WBCT. The remaining patients underwent radiographs, ultrasound or selective CT scans based on clinical examination. The median fetal radiation doses were 38 mGy [23–63] and 0 mGy [0–1]. Maternal mortality (6%) was lower than fetal mortality (17%). Two women (out of 3 maternal deaths) and 7 fetuses (out of 9 fetal deaths) died within the first 24 h following trauma. Conclusions Immediate WBCT for initial injury assessment in pregnant women with trauma was associated with a fetal radiation dose below the 100 mGy threshold. Among the selected population with either a stable status with a moderate and nonthreatening injury pattern or isolated penetrating trauma, a selective strategy seemed safe in experienced centres.

Background Fibrinogen concentrate is widely used in traumatic hemorrhagic shock despite weak evidence in the literature. The aim of the study was to evaluate the effect of fibrinogen concentrate administration within the first 6 hours on 24-hour all-cause mortality in traumatic hemorrhagic shock using a causal inference approach. Methods Observational study from a French multicenter prospective trauma registry was performed. Hemorrhagic shock was defined as transfusion of four or more red blood cell units within the first 6 hours after admission. The confounding variables for the outcome (24-hour all-cause mortality) and treatment allocation (fibrinogen concentrate administration within the first 6 hours) were chosen by a Delphi method. The propensity score was specified with a data-adaptive algorithm and a doubly-robust approach with inverse proportionality of treatment weighting allowed to compute the average treatment effect. Sensitivity analyses were performed. Results Of 14,336 patients in the registry during the study period, 1,027 in hemorrhagic shock were analyzed (758 receiving fibrinogen concentrate within 6 hours and 269 not receiving fibrinogen concentrate). The average treatment effect, expressed as a risk difference, was -0.031 (95% confidence interval, -0.084 to 0.021). All sensitivity analysis confirmed the results. Conclusions Fibrinogen concentrate administration within the first 6 hours of a traumatic hemorrhagic shock did not decrease 24-hour all-cause mortality. Level of evidence Prognostic, level III.

Traumatic hemorrhagic shock (THS) is a complex, dynamic process and, no consensual definition of THS is available. This study aims (1) to explore existing definitions of traumatic hemorrhagic shock (THS), (2) to identify essential components of these definitions and (3) to illustrate in a pragmatic way the consequences of applying five of these definitions to a trauma registry.We conducted (1) a scoping review to identify the definitions used for traumatic hemorrhagic shock (THS); (2) an international experts survey to rank by relevance a selection of components extracted from these definitions and (3) a registry-based analysis where several candidate definitions were tested in a large trauma registry to evaluate how the use of different definitions affected baseline characteristics, resources use and patient outcome.Sixty-eight studies were included revealing 52 distinct definitions. The most frequently used was "a systolic blood pressure (SBP) less than or equal to 70 mmHg or between 71 and 90 mmHg if the heart rate is greater than or equal to 108 beats per min". The expert panel identified base excess, blood lactate concentration, SBP and shock index as the most relevant physiological components to define THS. Five definitions of THS were tested and highlighted significant differences across groups on important outcomes such as the proportion of massive transfusion, the need for surgery, in-hospital length of stay or in-hospital mortality.This study demonstrates a large heterogeneity in the definitions of THS suggesting a need for standardization. Five candidate definitions were identified in a three-step process to illustrate how each shapes study cohort composition and impacts outcome. The results inform research stakeholders in the choice of a consensual definition.

Background Deviation from guidelines is frequent in emergency situations and this may lead to increased mortality. Probably because of time constraints, 55% is the greatest reported guidelines compliance rate in severe trauma patients. This study aimed to identify among all available recommendations a reasonable bundle of items that should be followed to optimize the outcome of hemorrhagic shocks (HS) and severe traumatic brain injuries (TBI). Methods We first estimated the compliance with French and European guidelines using the data from the French TraumaBase® registry. Then, we used a machine learning procedure to reduce the number of recommendations into a minimal set of items to be followed to minimize 7-day mortality. We evaluated the bundles using an external validation cohort. Results This study included 5,924 trauma patients (1,414 HS and 4,955 TBI) between 2011 and August 2019 and studied compliance to 36 recommendation items. Overall compliance rate to recommendation items was 71.6% and 66.9% for HS and TBI respectively. In HS, compliance was significantly associated with 7-day decreased mortality in univariate analysis but not in multivariate analysis (RR = 0.91, 95%CI = 0.90-1.17, p = 0.06). In TBI, compliance was significantly associated with decreased mortality in univariate and multivariate analysis (RR = 0.85, 95%CI = 0.75-0.92, p = 0.01). For HS, the bundle included 13 recommendation items. In the validation cohort, when this bundle was applied, patients were found to have a lower 7-day mortality rate (RR = 0.46, 95%CI = 0.27-0.63, p = 0.01). In TBI, the bundle included 7 items. In the validation cohort, when this bundle was applied, patients had a lower 7-day mortality rate (RR = 0.55, 95%CI = 0.34-0.71, p = 0.02). Discussion Using a machine-learning procedure, we were able to identify a subset of recommendations that minimizes 7-day mortality following traumatic HS and TBI. These two bundles remain to be evaluated in a prospective manner. Level of evidence II.

Background During the SARS-CoV-2 pandemic, the French Government imposed various containment strategies, such as severe lockdown (SL) or moderate lockdown (ML). The aim of this study was to evaluate the effect of both strategies on severe trauma admissions and ICU capacity in Ile-de-France region (Paris Area). Main text We conducted a multicenter cohort-based observational study from 1stJanuary 2017 to 31th December 2020, including all consecutive trauma patients admitted to the trauma centers of Ile-de-France region participating in the national registry (Traumabase®). Two periods were defined, the “non-pandemic period” (NPP) from 2017 to 2019, and the “pandemic period” (PP) concerning those admitted in 2020. The number of ICU beds released during 2020 pandemic period (overall period, SL and ML) was estimated by multiplying difference in trauma admissions by the median length of stay during the same week of pandemic period (ICU day-beds in 2020). A 15% yearly reduction of trauma patients was observed during the PP, associated with the release of 6422 ICU day-beds in 2020. During SL and ML, the observed decrease in trauma admission was respectively 49 and 39% compared with similar dates of the NPP. The number of beds released was 1531 days-beds in SL and 679 day-beds in ML. Those reductions respectively accounted for 4.5 and 6.0% of the overall ICU admission for COVID-19 in Ile-de-France. Conclusion The lockdown strategies during pandemic resulted in a reduction of severe trauma admissions. In addition to the social distancing effect, lockdown strategies freed up an important number of ICU beds in trauma centers, available for severe COVID-19 patients.

Blunt cerebrovascular injuries (BCVI) are a rare but serious complication after trauma. Among patients with BCVI, neurological status is altered in 30% of cases and the prognosis seems to be associated with ischemic complications. The aim of this study was to assess the long-term outcome of BCVI-associated ischemic events.This retrospective cohort study (2011-2017) included all patients admitted for severe trauma with identified BCVI in two level-1 trauma centers. Patients were considered to have a poor neurological outcome with a GOS-E between 2 and 5 and a good neurological outcome with GOS-E between 6 and 8. A multivariate logistic regression identified risk factors for poor neurological outcome at 1 year.Of the 6,294 patients admitted in both trauma centers between 2011 and 2017, 81 patients presenting BCVI were identified (incidence of 1.3%). The median age was 35 years (24-44) with a median Injury Severity Score of 28 (17-41). 29 patients (50%) had a good neurological prognosis, while 25 patients (43%) had a poor neurological prognosis at 1 year. Ischemic stroke occurred in 11 patients (13.6%) within a median time of 2 days (2-2.5). No ischemic stroke occurred in the first year after ICU discharge in both groups. In our study, good prognosis at 1 year was not associated with ischemic complications [3 (10) vs 3 (12) p = 1].Ischemic complications after BCVI are rare, occur within the first week and do not seem to impact independently the 1-year neurological prognosis.

Background and AimsPatients with cirrhosis and acute-on-chronic liver failure (ACLF) have immunosuppression, indicated by an increase in circulating immune-deficient monocytes. The aim of this study was to investigate simultaneously the major blood-immune cell subsets in these patients.Material and MethodsBlood taken from 67 patients with decompensated cirrhosis (including 35 critically ill with ACLF in the intensive care unit), and 12 healthy subjects, was assigned to either measurements of clinical blood counts and microarray (genomewide) analysis of RNA expression in whole-blood; microarray (genomewide) analysis of RNA expression in blood neutrophils; or assessment of neutrophil antimicrobial functions.ResultsSeveral features were found in patients with ACLF and not in those without ACLF. Indeed, clinical blood count measurements showed that patients with ACLF were characterized by leukocytosis, neutrophilia, and lymphopenia. Using the CIBERSORT method to deconvolute the whole-blood RNA-expression data, revealed that the hallmark of ACLF was the association of neutrophilia with increased proportions of macrophages M0-like monocytes and decreased proportions of memory lymphocytes (of B-cell, CD4 T-cell lineages), CD8 T cells and natural killer cells. Microarray analysis of neutrophil RNA expression revealed that neutrophils from patients with ACLF had a unique phenotype including induction of glycolysis and granule genes, and downregulation of cell-migration and cell-cycle genes. Moreover, neutrophils from these patients had defective production of the antimicrobial superoxide anion.ConclusionsGenomic analysis revealed that, among patients with decompensated cirrhosis, those with ACLF were characterized by dysregulation of blood immune cells, including increases in neutrophils (that had a unique phenotype) and macrophages M0-like monocytes, and depletion of several lymphocyte subsets (including memory lymphocytes). All these lymphocyte alterations, along with defective neutrophil superoxide anion production, may contribute to immunosuppression in ACLF, suggesting targets for future therapies.

Additional file 2. Supplementary table on baseline characteristics for intubated vs spontaneously breathing patients.

Additional file 3. Multivariate full model including factors used in propensity score.

Tranexamic acid (TXA) use in severe trauma remains controversial notably because of concerns of the applicability of the CRASH-2 study findings in mature trauma systems. The aim of our study was to evaluate the outcomes of TXA administration in severely injured trauma patients managed in a mature trauma care system.We performed a retrospective study of data prospectively collected in the TraumaBase registry (a regional registry collecting the prehospital and hospital data of trauma patients admitted in six Level I trauma centers in Paris Area, France). In hospital mortality was compared between patients having received TXA or not in the early phase of resuscitation among those presenting an unstable hemodynamic state. Propensity score for TXA administration was calculated and results were adjusted for this score. Hemodynamic instability was defined by the need of packed red blood cells (pRBC) transfusion and/or vasopressor administration in the emergency room (ER).Among patients meeting inclusion criteria (n = 1,476), the propensity score could be calculated in 797, and survival analysis could be achieved in 684 of 797. Four hundred seventy (59%) received TXA, and 327 (41%) did not. The overall hospital mortality rate was 25.7%. There was no effect of TXA use in the whole population but mortality was lowered by the use of TXA in patients requiring pRBC transfusion in the ER (hazard ratio, 0.3; 95% confidence interval, 0.3-0.6).The use of TXA in the management of severely injured trauma patients, in a mature trauma care system, was not associated with reduction in the hospital mortality. An independent association with a better survival was found in a selected population of patients requiring pRBC transfusion in the ER.Therapeutic study, level III.

Introduction: Balanced analgesia, using both opioid and non-opioids agents, has become the standard care for postoperative pain management. Ketamine, a compound with analgesic and antihyperalgesic properties, has been shown to decrease postoperative pain and opioid requirements in adults. The goal of the present meta analysis was to investigate postoperative analgesic properties of ketamine in pediatric patients. Material and Methods: A comprehensive literature search was conducted to identify clinical trials that used ketamine as a perioperative analgesic compound in children and infants. Outcomes measured were: postoperative analgesic consumption, pain intensity and duration of sensory block (when ketamine was used by caudal route) during the PACU (Postoperative Care Unit) stay and the early postoperative period (6 to 24 hours after leaving the operative room). The data from each trial were combined to calculate the pooled odds ratios or standard mean differences and their 95% confidence intervals. Results: Thirty five randomized, blinded controlled studies were retrieved from the literature. Systemic ketamine was effective in decreasing PACU pain intensity and analgesic requirement but failed to influence early (6 to 24 hours) pain intensity and analgesic requirement. Ketamine administered locally during tonsillectomy, decreased PACU and early (6 to 24 hours) pain intensity and PACU analgesic requirements. Used as an adjuvant for caudal analgesia, ketamine increased the duration of sensory block and PACU analgesic requirement without impacting PACU pain intensity. Ketamine failed to exhibit a postoperative opioid-sparing effect. Conclusions: This meta analysis found that administration of ketamine was associated with decreased PACU postoperative pain intensity and non-opioid analgesic requirement. However, ketamine failed to exhibit a postoperative opioid-sparing effect.

Balanced analgesia, using both opioid and nonopioids agents, has become the standard care for postoperative pain management. Ketamine, a compound with analgesic and antihyperalgesic properties, has been shown to decrease postoperative pain and opioid requirements in adults. The goal of the present meta-analysis was to investigate postoperative analgesic properties of ketamine in pediatric patients.A comprehensive literature search was conducted to identify clinical trials that used ketamine as a perioperative analgesic compound in children and infants. Outcomes measured were postoperative analgesic consumption, pain intensity and duration of sensory block (when ketamine was used by caudal route) during the postoperative care unit (PACU) stay and the early postoperative period (6-24 h after leaving the operative room). The data from each trial were combined to calculate the pooled odds ratios or standard mean differences and their 95% confidence intervals.Thirty-five randomized, blinded controlled studies were retrieved from the literature. Systemic ketamine was effective in decreasing PACU pain intensity and analgesic requirement but failed to influence early (6-24 h) pain intensity and analgesic requirement. Ketamine administered locally during tonsillectomy, decreased PACU and early (6-24 h) pain intensity and PACU analgesic requirements. Used as an adjuvant for caudal analgesia, ketamine increased the duration of sensory block and PACU analgesic requirement without impacting PACU pain intensity. Ketamine failed to exhibit a postoperative opioid-sparing effect.This meta-analysis found that administration of ketamine was associated with decreased PACU postoperative pain intensity and nonopioid analgesic requirement. However, ketamine failed to exhibit a postoperative opioid-sparing effect.

The "perioperative" period for elderly patients is prone to a significant level of morbidity and mortality. Chronological age and comorbidities are the main causes of mortality. Loco-regional anaesthesia is used in 50% of cases. When general anaesthesia is used, invasive monitoring is the rule, with titration of medication and pain treatment. Cognitive dysfunctions are related to age rather than the anaesthetic technique. The aim is for early rehabilitation perhaps through ambulatory care.

Introduction Apres transplantation hepatique (TH), la non-fonction primaire (NFP) et la dysfonction primaire (DFP) du greffon sont associees a une morbi-mortalite importante. La NFP survient dans 5 % des cas mais aboutit au deces en l’absence de reTH et la DFP multiplie la mortalite par 10. La frequence de ces complications augmente avec l’utilisation de greffons « marginaux ». Actuellement, le score Donor Risk Index (DRI) reprend les criteres de greffon marginal exposant au risque de DFP mais aucun biomarqueur mesure chez le donneur ne permet de predire les dysfonctions du greffon chez le receveur [1] . L’alpha-gluthation-S-transferase (α-GST) est une enzyme hepatocytaire qui pourrait constituer un marqueur precoce de souffrance hepatocellulaire. Une technique de dosage plasmatique a ete developpee pour permettre sa mesure en routine. L’objectif de ce travail est d’etudier la capacite du dosage d’α-GST chez le donneur a predire la DFP et la NFP chez le receveur. Materiel et methodes Apres accord du comite d’ethique, de mars 2014 a fevrier 2015, du sang issu du tube du donneur, collecte au moment du prelevement d’organe et destine au controle ultime ABO, a ete centrifuge puis le plasma congele apres la realisation du controle. Le dosage de l’α-GST a ete realise sur 100 μL de plasma grâce au kit Fastpack IP α-GST Immunoassay™ (Qualigen, Carlsbad, CA). Les donnees demographiques et biologiques des donneurs ont ete obtenues via le dossier de l’Agence de biomedecine et celles des receveurs recueillies prospectivement durant les 7 premiers jours apres TH. Le DRI a ete calcule. La NFP et la DFP etaient definies selon Olthoff et al. [2] . L’analyse statistique comprenait correlation de Spearman, tests non parametriques et regression logistique. Les resultats sont exprimes en median [range] ou pourcentage. Resultats Soixante-deux TH pour cirrhose (43 % d’homme, MELD = 14,5) compliquees de 14 (26 %) DFP dont 2 (4 %) NFP ont ete realisees sur la periode. Les dosages d’α-GST du donneur de 54 TH ont ete analyses (8 tubes du donneur non obtenus). Les valeurs de GST du donneur etaient significativement plus elevees en cas de NFP et de DFP ( Tableau 1 ) contrairement a celles de DRI. Chez le donneur, la concentration plasmatique d’α-GST etait positivement correlee a celle des ASAT et ALAT (p Discussion Actuellement, aucun marqueur ne permet de predire le risque de NFP et de DFP. Ces resultats preliminaires suggerent que l’α-GST plasmatique du donneur pourrait predire une dysfonction de greffon. Ceci doit etre confirme dans une cohorte plus importante mais pourrait se reveler interessant pour reconnaitre un greffon hepatique a risque avant le prelevement.

Introduction Apres transplantation hepatique (TH), la survenue d’une non-fonction primaire (NFP) ou d’une dysfonction primaire (DFP) de greffon est associee a une morbi-mortalite importante. La reconnaissance de ces evenements doit etre la plus rapide possible afin de mettre en place des strategies adaptees, pouvant aller jusqu’a une retransplantation rapide. Cependant, il n’existe pas actuellement de moyen de predire precocement ces complications. L’alpha-gluthation-S-transferase (α-GST), enzyme intrahepatocytaire a demi-vie courte, pourrait etre un temoin precoce de souffrance hepatocellulaire. Son dosage est depuis peu rendu possible en routine par methode Elisa sur des echantillons sanguins. L’objectif principal de cette etude est d’evaluer la capacite du dosage repete d’α-GST chez le receveur a reconnaitre la DFP et la NFP post-TH. Materiel et methodes De mars 2014 a fevrier 2015, 54 TH pour cirrhose ont ete incluses. Apres accord du comite d’ethique, durant les 5 premiers jours post-TH, 3 mL de sang ont ete quotidiennement collectes chez les receveurs, puis centrifuges et congeles. Les dosages plasmatiques d’α-GST ont ete realises a partir de 100 μL de ce plasma grâce au kit Fastpack IP α-GST Immunoassay™ (Qualigen Inc., Carlsbad, CA). Les donnees cliniques et biologiques des 5 premiers jours post-TH ont ete recueillies de maniere prospective. La NFP et la DFP etaient definies selon Olthoff et al. [1] . L’analyse statistique comprenait correlation de Spearman, tests du Chi2 et de Mann-Withney pour l’analyse univariee et une regression logistique pour l’analyse multivariee. Les resultats sont exprimes en mediane [range] ou pourcentage. Resultats Parmi les 54 TH etudiees, 14 cas de DFP et 2 cas de NFP on ete observes (26 % et 4 % respectivement). Le MELD median etait de 14,5. Les valeurs d’α-GST du receveur a son arrivee en reanimation et a j1 post-TH etaient correlees aux valeurs des ALAT et ASAT a ces memes moments (p Fig. 1 ). Dans les deux cas, a partir de j2, les valeurs diminuaient de facon comparable pour rapidement se normaliser. L’analyse de la courbe ROC a montre que le dosage de l’α-GST chez le receveur a j1 predisait la survenue d’une DFP avec une AUC egale a 0,75. La valeur seuil de 121 ng/mL permettait de predire la DFP avec une sensibilite de 73 % et une specificite de 79 %. Discussion Actuellement, aucun biomarqueur ou score predictif ne permet de reconnaitre precocement la DFP de greffon. Nos resultats montrent que des j1 post-TH, la concentration de l’α-GST dans le plasma du receveur pourrait permettre de predire la survenue d’une DFP de greffon et d’adapter precocement la prise en charge des patients.

Introduction L’encephalopathie hepatique (EH) est une pathologie frequente en cas de maladie hepatique, aussi bien en cas d’insuffisance hepatique aigue (IHA) qu’en cas de cirrhose. En cas d’IHA, elle est associee a des perturbations de l’hemodynamique intracerebrale et de l’autoregulation cerebrale pouvant aboutir a une hypertension intracrânienne [1] . Dans ces circonstances, les modalites de surveillance neurologique sont tres peu etudiees. L’indice de pulsatilite (IP) mesure par Doppler transcrânien (DTC) pourrait permettre une meilleure surveillance dans cette population specifique. L’objectif de ce travail etait de decrire l’evolution de l’IP avant et au decours de la TH chez des patients souffrant d’EH dans un contexte d’IHA ou de cirrhose. Materiel et methodes Apres accord du comite d’ethique, des mesures d’IP au niveau de l’artere cerebrale moyenne par DTC ont ete realisees en pre- et en post-TH chez des patients cirrhotiques sans antecedent d’EH, avec antecedent d’EH aigue ou chronique et en cas d’IHA. Ces mesures etaient realisees quotidiennement jusqu’a reveil et extubation post-TH. Le stade d’EH pre-TH ou le pire stade d’EH deja decrit, selon la classification de West Haven, ont ete colliges. Les donnees demographiques, biologiques et postoperatoires ont egalement ete recueillies. Le j0 post-TH est defini dans notre service comme le jour de sortie du bloc operatoire. Les resultats sont presentes en mediane [IQR] ou pourcentage. Resultats De janvier 2013 a decembre 2014, des mesures d’IP ont ete realisees chez 41 patients : 5 patients cirrhotiques sans EH (groupe temoin), 22 cirrhotiques avec antecedent d’EH aigue ou chronique et 14 IHA. En absence d’EH, les valeurs d’IP pre- et post-TH a j0 etaient normales, respectivement 1,01 [0,84–1,03] et 1,07 [1,06–1,08]. Chez les cirrhotiques avec EH, l’IP post-TH etait legerement augmentee par rapport a l’IP pre-TH, respectivement 1,25 [1,01–1,44] et 1,05 [1–1,26]. Cette valeur se normalise ensuite des j1. En cas d’IHA, des resultats similaires sont retrouves (IP pre-TH 1,12 [1,03–1,27], IP j0 1,38 [0,96–1,52]). En cas d’IHA et d’EH severe (grade 3 et 4), les valeurs d’IP pre-TH etaient significativement superieures a celles des patients avec EH legere (grade 1 et 2) ( Fig. 1 , respectivement 1,48 [1,22–1,66] vs 1,04 [0,99–1,12], p = 0,01). Ce resultat etait retrouve a j0 mais sans atteindre le seuil de significativite (1,55 [1,49–1,67] vs 0,84 [0,75–1,08]). Discussion En cas d’IHA avec EH, la surveillance de l’IP de l’artere cerebrale moyenne par DTC en pre- et en post-TH permet de detecter des alterations de l’hemodynamique cerebrale qui se normalisent 24 a 36 heures apres la TH. La surveillance du DTC pourrait permettre, de surveiller et adapter les therapeutiques de neuroreanimation en cas d’IHA compliquee d’EH severe.

Introduction L’efficacite de la reanimation de l’arret cardiorespiratoire intrahospitalier (ACRIH) necessite des connaissances theoriques et pratiques de tous les acteurs de la chaine de survie. Dans ce cadre, le groupe « urgences vitales » de notre etablissement propose des formations aux gestes d’urgence ayant pour objectif une amelioration des savoirs et des pratiques [1] . Elles sont realisees une fois par mois, pendant 3 heures, par un binome IDE/IADE du SAR a destination de tout le personnel soignant sur la base du volontariat. L’objectif de cette etude etait d’evaluer le niveau de connaissance sur la PEC de l’ACRIH des soignants. Patients et methodes Enquete declarative un jour donne, en octobre 2014, aupres des personnels presents dans les differentes unites de l’etablissement (jour/nuit) a l’exception des blocs operatoires, du SAR et du SAU. Cette enquete etait menee par un binome IDE/MAR a partir d’un questionnaire de 11 items portant sur des connaissances theoriques et pratiques [2] . Resultats Trois cent soixante-cinq soignants ont ete interroges ( Fig. 1 ). Cinquante pour cent avaient eu la formation sur les gestes d’urgence dans les 3 ans. Les resultats de l’enquete sont presentes dans le Tableau 1 . Discussion Quarante pour cent des reponses sont non conformes ou insuffisantes. Ce taux modere de retention de l’information suggere la necessite de renouveler ces formations ou d’en modifier son organisation. Doit-on rendre cette formation obligatoire ? Doit-elle s’organiser sous la forme de simulation ? Certaines constatations comme la non connaissance du numero d’alerte suggerent des actions correctrices independantes. Au sein d’un etablissement de sante, l’aptitude des soignants a prendre en charge de facon adaptee un ACRIH represente un enjeu important. L’evaluation des connaissances est indispensable et permet de reflechir a des methodes d’amelioration de ces aptitudes.

Introduction Lors de la transplantation hepatique (TH), la candidose invasive (CI) est associee a une morbi-mortalite postoperatoire importante [1] . Les recommandations preconisent une prophylaxie antifongique chez les patients presentant au moins 2 facteurs de risque (FDR) parmi les suivants : retransplantation, creatininemie preoperatoire superieure a 177 μmol/L, anastomose bilio-digestive, transfusion massive peroperatoire, duree operatoire prolongee et colonisation fongique en perioperatoire de TH [2] . Les donnees sur l’interet du depistage de la colonisation fongique dans ce contexte sont pauvres et anciennes. Ce travail a pour but d’evaluer l’apport de la cartographie fongique chez les patients transplantes hepatiques. Materiel et methodes Etude monocentrique retrospective a partir d’une base de donnees prospective des TH de janvier 2010 a decembre 2013. Les patients ayant beneficie d’une cartographie fongique sont etudies. Une cartographie fongique positive est definie par la presence de levures sur au moins 2 sites non contigus, en l’absence de signe d’infection. Le diagnostic de CI est retenu en cas d’infection fongique prouvee : candidemie, peritonite ou infection de liquide d’ascite. L’ecologie fongique, la realisation d’une prophylaxie antifongique, la survenue d’une CI, la mortalite en reanimation et les FDR de CI ont ete etudies en analyse univariee. Les resultats sont exprimes en mediane [intervalles interquartiles], en nombre (pourcentage) et analyses par des tests non parametriques. Resultats Sur 426 TH realisees entre 2010 et 2013, 68 patients (78 TH) presentant au moins 1 FDR ont eu une cartographie fongique (delai entre TH et realisation de la cartographie fongique : 3 [1–7,5] jours). La mortalite en reanimation de cette population etait de 29 %. 46 cartographies (68 %) sont positives ( Fig. 1 ). Aucun facteur de risque de colonisation fongique n’a pu etre mis en evidence. 19 (33 %) patients ont presente une CI (delai entre TH et survenue de CI : 12,5 [6,75–19,25] jours). La mortalite en reanimation associee a une CI etait de 3 patients sur 19 (16 %). Parmi les 14 patients ayant eu une cartographie positive et developpe une CI, 13 (93 %) se sont infectes au meme germe ( Tableau 1 , Fig. 1 ). Discussion Dans cette population de transplantes hepatiques a haut risque d’infection fongique, recevant une prophylaxie antifongique dans 59 % des cas, les resultats de la cartographie fongique ne semblent pas associes au risque de CI ulterieure. Ceci reste a confirmer sur une population plus importante.

Early diagnosis of acute mesenteric ischemia (AMI) remains a clinical challenge, and no biomarker has been consistently validated. We aimed to assess the accuracy of three promising circulating biomarkers for diagnosing AMI—citrulline, intestinal fatty acid-binding protein (I-FABP), and d-lactate. A cross-sectional diagnostic study enrolled AMI patients admitted to the intestinal stroke center and controls with acute abdominal pain of another origin. We included 129 patients—50 AMI and 79 controls. Plasma citrulline concentrations were significantly lower in AMI patients compared to the controls [15.3 μmol/L (12.0–26.0) vs. 23.3 μmol/L (18.3–29.8), p = 0.001]. However, the area under the receiver operating curves (AUROC) for the diagnosis of AMI by Citrulline was low: 0.68 (95% confidence interval = 0.58–0.78). No statistical difference was found in plasma I-FABP and plasma d-lactate concentrations between the AMI and control groups, with an AUROC of 0.44, and 0.40, respectively. In this large cross-sectional study, citrulline, I-FABP, and d-lactate failed to differentiate patients with AMI from patients with acute abdominal pain of another origin. Further research should focus on the discovery of new biomarkers.