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International audience; Purpose: In patients with COPD, one of the leading indications for domiciliary non-invasive ventilation (NIV), a major paradigm shift has been observed over the past decade in the method for adjusting NIV settings, with the use of sufficient ventilatory support to achieve a significant reduction in PaCO2. Whether this approach may be relevant to other populations, especially slowly progressive neuromuscular diseases (NMD), is unknown.Methods: This study was conducted as a post hoc analysis from a previously published randomized controlled trial (NCT03458507). Patients with NMD treated with domiciliary NIV were stratified according to the level of ventilatory support: high-level tidal volume (HLVT; mL/kg of predicted body weight [PBW]) or high-level pressure support (HLPS), defined as a value above median value of the whole population (> 6.8 mL/kgPBW or 9.0 cmH2O, respectively). Primary outcome was mean nocturnal transcutaneous CO2 pressure (PtcCO2). Secondary outcomes included adherence to NIV, leaks, and side effects.Results: Of a total of 26 patients, 13 were exposed to HLVT, with significantly lower nocturnal PtcCO2 (respectively 40.5 ± 4.2 vs. 46.3 ± 3.9 mmHg, p = 0.002). A linear correlation between VT (mL/kgPBW) and mean nocturnal PtcCO2 was evidenced (r = - 0.59, 95%CI [- 0.80; - 0.25], p = 0.002). No significant impact of HLVT was found on secondary outcomes.Conclusion: Despite the lack of power of this post hoc analysis, our results suggest that higher levels of ventilatory support are correlated with lower PtcCO2 in patients with NMD. Further studies are desirable to assess the extent to which the level of assistance influences PaCO2 evolution in patients with slowly progressive NMD, as well as in restrictive thoracic disorders.

International audience; Question: In people with non-small cell lung cancer, what is the effect of condensing 15 prehabilitation sessions into a 3-week regimen compared with a 5-week regimen?Design: Randomised controlled trial with concealed allocation, intention-to-treat analysis and blinded assessment of the primary outcome.Participants: People with diagnosed or suspected non-small cell lung cancer and moderate-to-high risk of postoperative complications. Intervention: Fifteen supervised prehabilitation sessions delivered with either a dense regimen of five sessions/week for 3 weeks (experimental group) or a non-dense regimen of three sessions/week for 5 weeks (control group).Outcome measures: The primary outcome was the change in cardiorespiratory fitness measured by the V̇O2peak in ml/kg/min. The secondary outcomes were the change in other variables of interest measured during cardiopulmonary exercise testing, non-invasive nutritional markers, quadriceps maximal voluntary isometric contractions, maximal inspiratory pressure, quality of life, adherence and postoperative complications.Results: Changes with the experimental regimen were similar to or better than changes with the control regimen for: V̇O2peak (MD 1.2 ml/kg/min, 95% CI −0.1 to 2.6); V̇E/V̇CO2 slope (MD −3.6 points, 95% CI −8.7 to 1.5); and work rate at ventilatory threshold (MD 3.7 W, 95% CI −5.6 to 13.0). The two regimens had similar effects on: peak work rate (MD 1.3 W, 95% CI −6.4 to 9.0), V̇O2 at ventilatory threshold (MD 0.0 ml/kg/min, 95% CI −1.4 to 1.4); body mass index (MD −0.2 kg/m2, 95% CI −0.5 to 0.1); and maximal inspiratory pressure (MD −0.7 cmH2O, 95% CI −9.8 to 8.4). The relative effect was uncertain for quadriceps maximal voluntary isometric contractions, quality of life and complications.Conclusion: Condensing prehabilitation sessions led to similar or better improvement in cardiorespiratory fitness and did not decrease adherence or increase adverse events. This could increase the number of patients who can be referred for prehabilitation, despite short presurgical periods. Trial registration: NCT03936764.

International audience; The scope of practice of podiatrists varies between countries. This distinction is strongly correlated with the level of educational requirements to become a podiatrist. In both the United Kingdom and the United States, the scope of practice of podiatrists has expanded over the course of the 20th century. Depending on their level of training, these professionals can perform minor or complex surgery. In Switzerland, Belgium and Spain, their training courses are also different. The legitimacy of podiatrists in surgical procedures is often disputed.

International audience; In order to understand how the profession of podiatrist is practised in France, it is necessary to trace its history. For a long time, the teaching of care was separated from that of fitting. The French title of pedicurist-podiatrist dates from 1984. The training for this profession in France is evolving towards a university degree and gives access to a doctorate in science. Podiatrists will be able to join university hospital departments to a greater extent. This recognition does not yet allow advanced practice.

International audience; Introduction: Le choix de l'abord chirurgical pour la réalisation d'une arthroplastie totale de hanche (ATH) ne fait pas consensus en orthopédie. Il existe un regain d'intérêt ces dernières années pour les voies antérieures mini-invasives (VAMI) dites anatomiques. Cependant, leur retentissement minoré n'a pas été confirmé par des imageries. Aussi nous avons mené une étude prospective destinée à : (1) évaluer l'infiltration graisseuse (IG) des muscles péri-articulaires de hanche, (2) analyser l’évolution de cette IG dans le temps. Hypothèse: Une ATH par VAMI induit une IG sur les muscles péri-articulaires antéro-latéraux adjacents à l'abord. Matériels et méthodes: Une série continue mono-opérateur d'ATH par VAMI sur table orthopédique a été réalisée par un opérateur entraîné. Des IRM (1,5Tesla OPTIMA MR360) ont été réalisées en préopératoire, puis à 3 mois et 1 an de la chirurgie. L'analyse de l'IG musculaire selon la classification de Goutallier était réalisée par un radiologue indépendant sur l'ensemble des muscles péri-articulaires de hanche. La comparaison était effectuée entre les IRM préopératoires et celles à 3 mois et 1 an à l'aide de tests de Wilcoxon. Résultats: Soixante-neuf IRM ont été réalisées sur 23 patients. Deux n’étaient pas interprétables du fait de mouvements du patient lors de l'acquisition préopératoire. Aucune complication peropératoire ni postopératoire n'a été rapportée dans cette série après 1 an de suivi. Tous les patients présentaient des hanches indolores sans boiterie à 1 an de l'intervention. L'analyse de l'IG montrait une aggravation significative de cette dernière entre les IRM préopératoires et celles à 3 mois (p = 0,02) et 1 an (p = 0,0007) au niveau du muscle obturateur interne ainsi qu’à 1 an (p = 0,04) au niveau du muscle piriforme. Aucune différence significative n’était retrouvée sur les autres muscles. Le muscle droit fémoral, les muscles jumeaux supérieurs et inférieurs ainsi que le muscle carré fémoral n’étaient pas analysables. Discussion: Notre hypothèse de départ n’était pas confirmée mais nous avons retrouvé un résultat paradoxal avec la mise en évidence d'une IG musculaire, cependant celle-ci n’était pas antéro-externe mais postérieure au niveau des muscles pelvi-trochantériens à la suite d'ATH par VAMI. Ces lésions pourraient être secondaires à des désinsertions ou des dénervations de ces muscles lors de l’élévation du fémur pour l'implantation fémorale. Niveau de preuve: IV; série prospective de cas.

BACKGROUND: Adaptive servoventilation (ASV) is a recently developed ventilation mode designed to stabilize ventilation in patients with central sleep apnea and Cheyne-Stokes respiration. Alternatively, modes aiming to maintain average ventilation over several breaths, such as average volume-assured pressure support (AVAPS) and intelligent volume-assured pressure support (iVAPS), could be efficient during ventilation instability by reducing central events. These modes are available on a variety of devices. This bench evaluation studied the response of these different modes and devices to simulated transient hypoventilation events. METHODS: Three home ventilation devices operating in ASV modes (AirCurve 10 CS Pacewave, ResMed; DreamStation autoSV, Philips; Prisma CR, Lowenstein) and 2 ventilators with the AVAPS mode (DreamStation BiPAP, Philips; Lumis 150 iVAPS, ResMed) were evaluated during transient central hypopnea/hypoventilation simulations characterized by a constant breathing frequency of 15 breaths/min and a progressive decrease of tidal volume (VT) from 500 mL to 50 mL, in 18, 12, 9, and 6 breaths, respectively, followed by a progressive return to the baseline at the same rate. RESULTS: The AirCurve 10 CS Pacewave reacted to a VT decrease between 80% and 50% of baseline VT. DreamStation BiPAP and Prisma CR reacted when VT decreased to between 60% and 30% of baseline VT, whereas the AVAPS response to hypopnea occurred during the crescendo phase of hypopnea/hypoventilation VT. The iVAPS response was between that of the AirCurve 10 CS Pacewave and the other ASV devices. Among the ASV devices, the minimum VT was higher with AirCurve 10 CS Pacewave, followed by the Prisma CR and the DreamStation BiPAP. Minimum VT was not influenced by AVAPS and was improved by iVAPS without outperforming the AirCurve 10 CS Pacewave. Maximum VT was increased by iVAPS, whereas ASV devices did not induce a significant VT overshoot. CONCLUSIONS: ASV devices improved central hypopnea/hypoventilation events without inducing hyperpnea events and therefore were better adapted than AVAPS and iVAPS devices, with notable differences in their responses to hypoventilation events.

BACKGROUND: High-flow nasal cannula (HFNC) is increasingly used for the management of respiratory failure. Settings include [Formula: see text] , total gas flow, and temperature target. Resulting absolute humidity (AH) at the nasal cannula may affect clinical tolerance, and optimal settings with respect to hygrometry remain poorly documented. METHODS: A bench study was designed to assess AH delivered by 4 HFNC devices (Optiflow, Airvo 2, Precision Flow, and Hydrate) according to flow, ambient temperature, and other available settings. Clinical tolerance of different levels of hygrometry (20, 30, and 40 mg H(2)O/L) was evaluated in 15 healthy volunteers. RESULTS: With [Formula: see text] set at 1.0, normal ambient temperature, and settings made accordingly to the manufacturers’ recommendations, mean ± SD AH was 42.2 ± 3.1, 39.5 ± 1.8, 35.7 ± 2.0, and 32.9 ± 2.7 mg H(2)O/L for the Airvo 2, Optiflow, Hydrate, and Precision Flow, respectively, (P < .001). AH dropped from −3.5 to −10.7 mg H(2)O/L (P

International audience; Background: Growing consideration is emerging regarding the burden of persisting sequelae after SARS-CoV-2 infection. Out-patients exhibiting long Covid may benefit from ambulatory rehabilitation which is, to date, poorly documented. Methods: A longitudinal follow-up over a one-year period was conducted in two ambulatory rehabilitation structures in order to describe the characteristics of real-life patients referred with Covid-19 sequelae and their evolution over the course of rehabilitation. Results: 39 consecutive patients were included from April 1st, 2020 to April 1st, 2021. Patients were middle-aged (48 ± 15yr), without comorbidities, and mostly mild to moderate SARS-CoV-2 infection (25(64%) not requiring hospitalisation). Rehabilitation referral was considered with a median delay of 73[34–178] days after disease onset. Most prevalent symptoms were dyspnoea (n = 35(90%)) and fatigue (n = 30(77%)). Hyperventilation syndrome was highly frequent (n = 12(34%)). 29(74%) patients presented with prolonged functional sequelae, which was associated with younger age (43 ± 14 vs. 50 ± 10yr; p = 0.002), greater prevalence of hyperventilation syndrome (n = 12(41%) vs. 0(0%); p = 0.255) and poorer quality of life (VQ-11; 31 ± 10 vs. 23 ± 9; p = 0.030). Over the course of rehabilitation, exertional dyspnoea, 6-min walking distance, 3-min sit-to-stand test, hyperventilation syndrome prevalence and quality of life significantly improved. Conclusion: Hyperventilation is frequent in long Covid and may explain persistent dyspnoea as well as altered quality of life. Our data support screening of hyperventilation syndrome and functional impairment in mild Covid-19 out-patients as both of these components may improve with ambulatory rehabilitation.

Graphical abstract, Introduction With the current COVID-19 pandemic, concerns have raised regarding the risk for NIV to promote airborne transmission. In case of hospital admission, continuation of therapy in patients undergoing chronic NIV is necessary and several protective circuit configurations have been recommended to reduce the risk of aerosol dissemination. However, all these configurations increase instrumental dead space. We therefore designed this study to evaluate their effects on the tidal volume (VTE) required to preserve stable end-tidal CO2 partial pressure (PETCO2) with constant respiratory rate. Methods A bench consisting of a test lung connected to an adult-sized mannequin head was set up. The model was ventilated through usual domiciliary configuration (single limb circuit with facial vented mask) which was used as reference. Then, five different circuit configurations including non-vented facial mask with viral/bacterial filter, modification of leak position, and change from single to double-limb circuit were evaluated. For each configuration, pressure support (PS) was gradually increased to reach reference PETCO2. Resulting VTE was recorded as primary outcome. Results Reference PETCO2 was 38(0) mmHg, with a PS set at 10 cmH2O, resulting in a VTE of 432(2) mL. Compared to reference, all the configurations evaluated required substantial increase in VTE to preserve alveolar ventilation, ranging from +79(2) to +216(1) mL. Conclusions Modifications of NIV configurations in the context of COVID-19 pandemic result in substantial increase of instrumental dead space. Re-evaluation of treatment efficiency and settings is crucial whenever protective measures influencing NIV equipment are considered.

International audience

Background Lateralization of the glenoid implant improves functional outcomes in Reverse Shoulder Arthroplasty. Lateralization does not appear to impact the Deltoid’s Moment Arm. Therefore, the stabilizing effect described in the literature would not be the result of an increase this moment arm. A static biomechanical model, derived from Magnetic Resonance Imaging, can be used to assess the coaptation effect of the Middle Deltoid. The objective of this study was to analyze the impact of increasing amounts of glenoid lateralization on the moment arm but also on its coaptation effect. Methods Eight patients (72.6 ± 6.5 years) operated for Reverse Shoulder Arthroplasty were included in the study. Three-dimensional models of each shoulder were created based on imaging taken at 6 months postoperative. A least square sphere representing the prosthetic implant was added to each 3D models. A static biomechanical model was then applied to different planar portions of the Middle Deltoid (from 3D models), first without lateralization and then with simulated lateralization of 6, 9 and 12mm. This static model enables to compute a Coaptation/Elevation Ratio and to measure the Deltoid’s Moment Arm. The inter- and intra-rater agreement of the 3D models was evaluated. Results One patient was excluded due to motion during imaging. The inter- and intra-rater agreement was over 0.99. The ratio increased starting at 6 mm of lateralization (p.05), compared to the initial position. The moment arm was not affected by lateralization (p.05), except in two slices starting at 9 mm (S1 p.05 and S2 p.05). Conclusion Our hypothesis that the Middle Deltoid’s coaptation role would be greater with glenosphere lateralization was confirmed. This trend was not found in the moment arm, which showed little sensitivity to lateralization. The stabilizing effect therefore appears to stem from the coaptation role of the Middle Deltoid.

Background Little interest has been paid to expiratory muscle strength, and the impact of expiratory muscle weakness on critical outcomes is not known. Very few studies assessed the relationship between maximal expiratory pressure (MEP) and critical outcomes. The aim of this study was to investigate the relationship between MEP and critical outcomes. Methods This work was a secondary analysis of a prospective, observational study of adult patients who required mechanical ventilation for ≥ 24 h in an 18-bed ICU. MEP was assessed before extubation after a successful, spontaneous breathing trial. The relationships between MEP and extubation failure, and short-term (30 days) mortality, were investigated. Univariate logistic regressions were computed to investigate the relationship between MEP values and critical outcomes. Two multivariate analyses, with and without maximal inspiratory pressure (MIP), both adjusted using principal component analysis, were undertaken. Unadjusted and adjusted ROC curves were computed to compare the respective ability of MEP, MIP and the combination of both measures to discriminate patients with and without extubation failure or premature death. Results One hundred and twenty-four patients were included. Median age was 66 years (IQR 18) and median mechanical ventilation duration was 7 days (IQR 6). Extubation failure rate was 15% (18/124 patients) and the rate for 30-day mortality was 11% (14/124 patient). Higher MEP values were significantly associated with a lower risk of extubation failure in the univariate analysis [OR 0.96 95% CI (0.93–0.98)], but not with short-term mortality. MEP was independently linked with extubation failure when MIP was not included in the multivariate model, but not when it was included, despite limited collinearity between these variables. This study was not able to differentiate the respective abilities of MEP, MIP, and their combination to discriminate patients with extubation failure or premature death (adjusted AUC for the combination of MEP and MIP: 0.825 and 0.650 for extubation failure and premature death, respectively). Conclusions MEP is related to extubation failure. But, the results did not support its use as a substitute for MIP, since the relationship between MEP and critical outcomes was no longer significant when MIP was included. The use of MIP and MEP measurements combined did not reach higher discriminative capacities for critical outcomes that MEP or MIP alone. Trial Registration This study was retrospectively registered at https://clinicaltrials.gov/ct2/show/NCT02363231?cond=NCT02363231&draw=2&rank=1 (NCT02363231) in 13 February 2015

Highlights • COVID-19 pneumonia is at risk of transfer in intensive care unit or death • Hydroxychloroquine+azithromycin seems to improve outcome of admitted patients • We report no major cardiac adverse event of this combination therapy, Introduction Interest of anti-infective agents in COVD-19 showed discrepant results. However, there is no evaluation about the impact in changes of practices on the prognosis over time. Methods Single center, retrospective study, conducted from March 5th to April 25th 2020, in adults hospitalized in a medicine ward for a COVID-19. Patient characteristics were compared between 2 periods (before/after March 19th) considering French guidelines issued by learned societies. Aim of the study was to evaluate how medical care impacted unfavorable outcome, namely admission in intensive care unit (ICU) and/or death. Results One hundred thirty-two patients were admitted, mean age was 59.0 ± 16.3 years, mean CRP level was 84.0±71.1 mg/L, 46% had a lymphocyte count

Resume Le virus SRAS-CoV-2, a l’origine de la pandemie actuelle de COVID-19, engendre des troubles respiratoires aigus qui peuvent conduire a une hospitalisation, essentiellement chez les personnes âgees. Le cas presente est celui d’une patiente de grand âge presentant une atteinte pulmonaire severe. Les evaluations motrices quotidiennes sur une semaine comprenaient le test Timed up and go, le test Five sit-to-stand, le test de force de serrage maximal et le recueil des constantes cardio-respiratoires (frequence cardiaque, respiratoire et saturation en oxygene). Une evaluation cognitive et de la qualite de vie ont aussi ete realises. Entre l’eva-luation initiale et finale, la duree de realisation du Timed Up and Go a diminue de 4,9 s, la performance au Five sit-to-stand est restee relativement stable, dans un contexte de sevrage de l’oxygene, de maintien de la saturation et d’une augmentation de la frequence respiratoire. Malgre un pronostic pejoratif, l’amelioration respiratoire de la patiente s’est accompagnee d’ameliorations motrices fonctionnelles. Les relations de regulations motrices et cardio-respiratoires sont discutees.

International audience; Protective ventilation should potentially be applied in most or all patients undergoing invasive mechanical ventilation.1,2 Reduction of tidal volume (VT) has progressively been incorporated over the years.3 Protective ventilation is not limited to VT reduction, however, but needs a combination of ventilator settings and associated procedures.1,4 The progressive reduction of VT has necessitated to increase the respiratory rate (RR), but no clear recommendation for setting the rate exists. In addition, the impact of dead space, including instrumental dead space (VDinstr), became highly relevant. Reducing the VDinstr should be recommended as part of lung protective ventilation,4 especially for patients requiring VT ≤ 6 mL/kg of predicted body weight (PBW).5 In this report, we reviewed data from the literature of the last 20 years to try to offer some clues to physicians on the questions of rate setting and the impact of dead space.

International audience; BACKGROUND: High-flow nasal cannula (HFNC) is increasingly used in the management of acute and chronic respiratory failure. Little is known about the optimal settings for HFNC. This study was designed to assess the dose effect of HFNC on respiratory effort indexes and respiratory patterns in spontaneously breathing adults. METHODS: A randomized controlled crossover study was conducted in 10 healthy subjects. Five experimental conditions were evaluated: baseline with no therapy; 5 L/min with conventional nasal prongs; and HFNC at 20, 40, and 60 L/min. The primary outcomes were the indexes of respiratory effort (ie, esophageal pressure swing [DPes], esophageal pressure-time product, and work of breathing). Secondary outcomes included breathing pattern parameters and blood gases. Dead-space ventilation and washout were calculated based on minute ventilation, breathing frequency, and Radford equations. RESULTS: DPes increased from median (interquartile range [IQR] 3.2 (2.2–3.6) cm H2O at baseline to median (IQR) 5.7 (4.6–6.8) cm H2O at 60 L/min (P < .001). Neither esophageal pressure-time product nor work of breathing were modified during the tested conditions. The minute volume was significantly reduced at 40 and 60 L/min compared with baseline (P = .04), mostly driven by an important and dose-dependent reduction in breathing frequency, from median (IQR) 16 (15–18) breaths/min at baseline, to median (IQR) 8 (7–10) breaths/min at 60 L/min (P < .001). Capillary PCO2 was stable in all the tested conditions. The calculated dead-space ventilation was reduced by half with HFNC. CONCLUSIONS: HFNC did not significantly modify work of breathing in healthy subjects. However, a significant reduction in the minute volume was achieved, capillary PCO2 remaining constant, which suggests a reduction in dead-space venti lation with flows > 20 L/min. (ClinicalTrials.gov registration NCT02495675).

Introduction In total hip arthroplasty (THA), the posterior approach is the most common throughout the world. Dislocation is one of the main complications incurred, but the risk may be reduced by sparing posterior structures. Thus, piriformis-sparing posterior approaches (PSPA) were described, and satisfactory conservation of the muscle was reported. On the other hand, a recent cadaver study reported occult intrapelvic piriformis lesions in 91% of cases. In the light of this discordance, we performed pre- and postoperative MRI in THA by PSPA: 1) to assess the fatty infiltration of the piriformis induced by the approach, with particular attention to intrapelvic lesions; and 2) to assess fatty infiltration of the other periarticular muscles. Hypothesis The piriformis muscle will show little fatty infiltration following PSPA. Materials and methods A continuous prospective single-surgeon series of THA by PSPA included 25 patients. MRI was performed preoperatively and at 3 months and 1 year postoperatively. Fatty infiltration was assessed on the Goutallier classification in all periarticular muscles. Results Preoperative MRI was lacking in 4 patients, who were excluded from analysis; 21 patients with MRI were thus analyzed. In the piriformis muscle, there was no significant change in fatty infiltration between preoperative and 3-month (p = 0.29) or 1-year (p = 0.41) MRI. Two of the 21 patients (9.5%) showed grade 3 or 4 fatty infiltration at 1 year, compared to 0/21 (0%) preoperatively; both showed sacral avulsion of the piriformis. Significant differences between preoperative and 1-year MRI were found for the obturator internus and externus, with grade 3 or 4 infiltration at 1 year in 14 cases for the obturator internus (14/21: 66.7%), in 3/21 for the obturator externus (14.3%) and in 6/21 for the quadratus femoris (28.6%), compared to respectively 0/21 (0%), 0/21 (0%) and 3/21 (14.3%) preoperatively. There were no significant differences for any of the other periarticular muscles. Conclusion PSPA in THA ensured good conservation of the piriformis. There may, however, be rare and irreversible sacral lesions invisible intraoperatively. Level of evidence IV; prospective case series.