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Community-acquired pneumonia is a commonly diagnosed illness in which no causative organism is identified in half the cases. Application of molecular diagnostic techniques has the potential to lead to more targeted therapy in the face of increasing antibiotic resistance.

La reanimation est une discipline peu reconnue dans les systemes de sante a ressources limitees. Le programme de cooperation francopakistanaise en reanimation de 2000 a 2010, entre le Pakistan Institute of Medical Sciences (PIMS), hopital universitaire d’Islamabad et le service de reanimation medicale de l’hopital Saint Antoine a Paris permet de mieux comprendre les defis poses au Pakistan par les patients necessitant des soins de reanimation, par la faiblesse du systeme de sante publique et par la lente emergence de la specialite. Le contexte socioculturel est un element essentiel pour expliquer les succes et les echecs de cette cooperation. Les actions se sont concentrees autour de la creation d’un service de reanimation medicale de neuf lits fonctionnant en systeme ferme avec une equipe dediee, d’un plaidoyer pour la reconnaissance de la specialite au niveau national, de la creation d’une formation diplomante en reanimation et de la redaction d’un projet de service soumis au ministere de la Sante. Les resultats sont incertains dans leur perennite, mais nous avons obtenu la reconnaissance de la discipline et des jeunes medecins s’engagent dans des parcours de formation specifiques. En 2014, la reanimation medicale du PIMS continue a fonctionner sur le mode ferme.

To determine the evolution of the outcome of patients with cirrhosis and septic shock.A 13-year (1998-2010) multicenter retrospective cohort study of prospectively collected data.The Collège des Utilisateurs des Bases des données en Réanimation (CUB-Réa) database recording data related to admissions in 32 ICUs in Paris area.Thirty-one thousand two hundred fifty-one patients with septic shock were analyzed; 2,383 (7.6%) had cirrhosis.None.Compared with noncirrhotic patients, patients with cirrhosis had higher Simplified Acute Physiology Score II (63.1 ± 22.7 vs 58.5 ± 22.8, p0.0001) and higher prevalence of renal (71.5% vs 54.8%, p0.0001) and neurological (26.1% vs 19.5%, p0.0001) dysfunctions. Over the study period, in-ICU and in-hospital mortality was higher in patients with cirrhosis (70.1% and 74.5%) compared with noncirrhotic patients (48.3% and 51.7%, p0.0001 for both comparisons). Cirrhosis was independently associated with an increased risk of death in ICU (adjusted odds ratio = 2.524 [2.279-2.795]). In patients with cirrhosis, factors independently associated with in-ICU mortality were as follows: admission for a medical reason, Simplified Acute Physiology Score II, mechanical ventilation, renal replacement therapy, spontaneous bacterial peritonitis, positive blood culture, and infection by fungus, whereas direct admission and admission during the most recent midterm period (2004-2010) were associated with a decreased risk of death. From 1998 to 2010, prevalence of septic shock in patients with cirrhosis increased from 8.64 to 15.67 per 1,000 admissions to ICU (p0.0001) and their in-ICU mortality decreased from 73.8% to 65.5% (p = 0.01) despite increasing Simplified Acute Physiology Score II. In-ICU mortality decreased from 84.7% to 68.5% for those patients placed under mechanical ventilation (p = 0.004) and from 91.2% to 78.4% for those who received renal replacement therapy (p = 0.04).The outcome of patients with cirrhosis and septic shock has markedly improved over time, akin to the noncirrhotic population. In 2010, the in-ICU survival rate was 35%, which now fully justifies to admit these patients to ICU.

Background In intensive care unit (ICU), infection and colonization by resistant Gram-negative bacteria increase costs, length of stay and mortality. Extended-spectrum beta-lactamase − producing Enterobacteriaceae (ESBL-E) is a group of pathogens increasingly encountered in ICU setting. Conditions that promote ESBL-E acquisition are not completely understood. The increasing incidence of infections related to ESBL-E and the unsolved issues related to ESBL-E cross-transmission, prompted us to assess the rates of referred and acquired cases of ESBL-E in ICU and to assess patient-to-patient cross-transmission of ESBL-E using a multimodal microbiological analysis. Methods During a 5-month period, all patients admitted to a medical ICU were tested for ESBL-E carriage. A rectal swab was performed at admission and then twice a week until discharge or death. ESBL-E strains were analyzed according to antibiotic susceptibility pattern, rep-PCR (repetitive-element Polymerase chain reaction) chromosomal analysis, and plasmid PCR (Polymerase chain reaction) analysis of ESBL genes. Patient-to-patient transmission was deemed likely when 2 identical strains were found in 2 patients hospitalized simultaneously in the ICU. Results Among the 309 patients assessed for ESBL-E carriage on admission, 25 were found to carry ESBL-E (importation rate: 8 %). During follow-up, acquisition was observed among 19 of them (acquisition rate: 6.5 %). Using the multimodal microbiological approach, we found only one case of likely patient-to-patient ESBL-E transmission. Conclusions In unselected ICU patients, we found rather low rates of ESBL-E referred and acquired cases. Only 5 % of acquisitions appeared to be related to patient-to-patient transmission. These data highlight the importance of jointly analyzing phenotypic profile and molecular data to discriminate strains of ESBL-E. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1489-z) contains supplementary material, which is available to authorized users.

Thenar eminence tissue oxygen saturation (StO(2)) was developed to assess organ perfusion. However, mottling, a strong predictor of mortality in septic shock, develops preferentially around the knee. We aimed to evaluate the prognostic value of StO(2) measured around the knee in septic shock patients and compare it to thenar StO(2).This was a prospective observational study in a tertiary teaching hospital. All consecutive patients with septic shock were included. Parameters were recorded when vasopressors were started (H0) and every 6 h during 24 h. Their predictive value was assessed on 14-day mortality.Fifty-two patients were included. SOFA score was 11 (9-15) and SAPS II was 56 (40-72). At 6 h after ICU admission (H6), mean arterial pressure, cardiac index, and central venous pressure were not different between non-survivors and survivors; but non-survivors had higher arterial lactate level (8.8 ± 5.0 vs. 2.2 ± 1.5 mmol/l, P0.001), lower urinary output (0.22 ± 0.45 vs. 0.70 ± 0.50 ml/kg/h, P0.001) and ScvO(2) (62 ± 20 vs. 72 ± 9 %, P = 0.03). At H6, StO(2) was lower in non-survivors; this difference was not significant for thenar StO(2) (70 ± 15 vs. 77 ± 12 %, P = 0.10) but was very pronounced for knee StO(2) (39 ± 23 vs. 71 ± 12 %, P0.001). At H6, a low knee StO(2) was associated with a higher mottling score (P0.01), a higher lactate level (P0.002, R (2) = 0.2), and a lower urinary output (P = 0.02, R (2) = 0.12).After initial septic shock resuscitation, StO(2) measured around the knee is a strong predictive factor of 14-day mortality.

Background Little is known about the efficacy of management of iatrogenic pneumothoraces with small-bore chest tubes. The aim of this study was to assess the outcome of iatrogenic pneumothoraces requiring drainage managed with a small-bore chest tube and to compare the results to spontaneous pneumothoraces treated in the same unit with the same device. The primary outcome was requirement of video-assisted thoracoscopic surgery for drainage failure; secondary outcomes were length of drainage and number of inserted chest tubes. Methods Patients with pneumothorax admitted between 1997 and 2007 were retrospectively identified. Traumatic pneumothoraces and those occurring under mechanical ventilation were excluded. All pneumothoraces were drained using the same small-bore chest tube (8 French) according to our local protocol. Results Five hundred sixty-one pneumothoraces were analysed, 431 (76.8%) were spontaneous pneumothoraces and 130 (23.2%) were iatrogenic. Iatrogenic pneumothoraces were associated with less requirement of video-assisted thoracoscopic surgery for drainage failure [adjusted odds ratio= 0.24 (0.04, 0.86)]. Length of drainage of iatrogenic pneumothoraces was longer than for primary spontaneous pneumothoraces (3.8 ± 3.1 vs. 2.7 ± 1.8 days, P

Experimental and clinical studies have identified a crucial role of microcirculation impairment in severe infections. We hypothesized that mottling, a sign of microcirculation alterations, was correlated to survival during septic shock.We conducted a prospective observational study in a tertiary teaching hospital. All consecutive patients with septic shock were included during a 7-month period. After initial resuscitation, we recorded hemodynamic parameters and analyzed their predictive value on mortality. The mottling score (from 0 to 5), based on mottling area extension from the knees to the periphery, was very reproducible, with an excellent agreement between independent observers [kappa = 0.87, 95% CI (0.72-0.97)].Sixty patients were included. The SOFA score was 11.5 (8.5-14.5), SAPS II was 59 (45-71) and the 14-day mortality rate 45% [95% CI (33-58)]. Six hours after inclusion, oliguria [OR 10.8 95% CI (2.9, 52.8), p = 0.001], arterial lactate level [1.5 OR 1; between 1.5 and 3 OR 3.8 (0.7-29.5);3 OR 9.6 (2.1-70.6), p = 0.01] and mottling score [score 0-1 OR 1; score 2-3 OR 16, 95% CI (4-81); score 4-5 OR 74, 95% CI (11-1,568), p0.0001] were strongly associated with 14-day mortality, whereas the mean arterial pressure, central venous pressure and cardiac index were not. The higher the mottling score was, the earlier death occurred (p0.0001). Patients whose mottling score decreased during the resuscitation period had a better prognosis (14-day mortality 77 vs. 12%, p = 0.0005).The mottling score is reproducible and easy to evaluate at the bedside. The mottling score as well as its variation during resuscitation is a strong predictor of 14-day survival in patients with septic shock.

Complicated abdominal aortic aneurysm (AAA) is a major cause of mortality in elderly men. Ang II-dependent TGF-beta activity promotes aortic aneurysm progression in experimental Marfan syndrome. However, the role of TGF-beta in experimental models of AAA has not been comprehensively assessed. Here, we show that systemic neutralization of TGF-beta activity breaks the resistance of normocholesterolemic C57BL/6 mice to Ang II-induced AAA formation and markedly increases their susceptibility to the disease. These aneurysms displayed a large spectrum of complications on echography, including fissuration, double channel formation, and rupture, leading to death from aneurysm complications. The disease was refractory to inhibition of IFN-gamma, IL-4, IL-6, or TNF-alpha signaling. Genetic deletion of T and B cells or inhibition of the CX3CR1 pathway resulted in partial protection. Interestingly, neutralization of TGF-beta activity enhanced monocyte invasiveness, and monocyte depletion markedly inhibited aneurysm progression and complications. Finally, TGF-beta neutralization increased MMP-12 activity, and MMP-12 deficiency prevented aneurysm rupture. These results clearly identify a critical role for TGF-beta in the taming of the innate immune response and the preservation of vessel integrity in C57BL/6 mice, which contrasts with its reported pathogenic role in Marfan syndrome.

Three women were consecutively admitted to our medical intensive care unit for thyrotoxicosis after the ingestion of dietary pills accidentally containing high levels of thyroxin. These cases were observed during an outbreak in the Paris area. Despite similar blood levels of thyroid hormones, their clinical presentation and outcome were very different. One patient developed febrile confusion and died from malignant hyperthermia. The second one had progressive confusion requiring mechanical plasma exchange therapy and had a favorable outcome. The third one had very moderate symptoms. These exceptional observations raise several issues concerning diagnosis, physiopathology and treatment of thyrotoxicosis factitia.

Resume L’endothelium est une monocouche cellulaire qui tapisse l’ensemble des vaisseaux de l’organisme. C’est un organe a part entiere qui joue un role fondamental dans le controle du tonus vasomoteur, dans le trafic cellulaire et macromoleculaire, dans le maintien de la fluidite sanguine et dans les processus d’angiogenese. Au cours du sepsis severe, il y a d’importantes modifications du phenotype endothelial, en grande partie responsable des defaillances d’organes. Les cellules endotheliales deviennent proadhesives, procoagulantes, antifibrinolytiques. La liberation endotheliale du NO est aussi fortement perturbee. La plupart des progres dans ce domaine proviennent d’etudes experimentales, les outils d’exploration d’endotheliale etant peu performants chez l’homme.

Background: Fluid therapy induces haemodilution related to plasma volume expansion. The aim of our study was to compare haemodilution after a single hydroxyethyl starches (HES) 130/0.4 infusion in two groups of patients, one with and one without sepsis. We hypothesized that a single HES challenge would induce similar sustained haemodilution in both groups. Methods: In this prospective preliminary study, patients predicted to require a single further volume-expander infusion were included immediately before receiving 500 ml of 6% HES 130/0.4 over a 15-min period. No additional fluid was administered over the next 8 h. Haematocrit, and serum albumin and protein were determined immediately before HES infusion then after 1, 2, 3, 4, and 8 h. Results: Twelve patients were included in each group. In both groups, all three haemodilution markers had significantly lower values after 1 h than at baseline. None of the values after 1 and 3 h differed significantly between the two groups. Neither did any of the other study variables show significant differences between the groups with and without sepsis. Conclusion: We found that a starch-based compound was as effective in inducing haemodilution in patients with sepsis as in controls without sepsis, suggesting that HES may remain within the intravascular space even in patients with sepsis. Haemodilution parameters such as haematocrit, serum albumin and serum protein are useful for assessing the duration of plasma volume expansion induced by fluid therapy in critically ill patients.

Although the demographic characteristics of patients who develop infective endocarditis (IE) have changed over the last few decades, Enterobacteriaceae remain rarely responsible. We report the clinical and epidemiological characteristics of 9 patients with native-valve Enterobacteriaceae IE from 6 French medical intensive care units over a 10-y period and have identified 29 additional cases in the literature. Nearly a third of the 38 patients were immunocompromised and/or had previously known valvular heart disease. Salmonella spp. and Yersinia spp. were the most frequently isolated microorganisms reported in the literature. The overall mortality rate was 24% (9/38) and was lower for operated patients (10% (1/10)) compared to those who did not undergo valve surgery (31% (8/26)). Our results confirmed the rarity of native-valve endocarditis caused by Enterobacteriaceae, pathogens frequently responsible for nosocomial and community-acquired bacteraemias. This paradox may be explained by susceptibility to the bactericidal action of serum and the inability of these bacteria to colonize the endocardium.

OBJECTIVE: Upper gastrointestinal bleeding (UGIB) related to stress ulcers was formerly a fearsome complication of intensive care. The incidence of this event has decreased over the years. However, the morbidity, mortality, and causes of UGIB, particularly the etiologic role of Helicobacter pylori infection, are still controversial. Therefore, we prospectively assessed the incidence of UGIB in the intensive care unit (ICU) and evaluated the role of H. pylori infection. DESIGN: A prospective observational study followed by a case-control study. SETTING: Seven ICUs in the Paris area, five of them located in teaching hospitals. PATIENTS: All patients admitted consecutively to seven ICUs during a 1-year period were monitored for signs of clinically relevant UGIB. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Only cases of endoscopically confirmed UGIB were analyzed. Patients whose hemorrhage originated from the stomach and/or duodenum were tested for H. pylori infection, by means of serology, histologic examination, and stool antigen detection. The possible association between H. pylori and UGIB was examined in a case-control study. Twenty-nine of the 4,341 patients admitted to the seven ICUs during the study period had clinically relevant, endoscopically confirmed UGIB (incidence, 0.67%; 95% confidence interval, 0.56%-0.77%). Ulcers were most frequently observed endoscopically. Patients who bled had a higher Simplified Acute Physiology Score (SAPS II) at admission (mean +/- sd, 47 +/- 14 vs. 36 +/- 28; p < .001). Despite a higher in-ICU mortality rate among patients who bled (73% vs. 16%; p < .001), death was never due to bleeding. H. pylori infection was more frequent in patients who bled than in matched controls (36% vs. 16%; p = .04). CONCLUSIONS: Clinically relevant, endoscopically confirmed UGIB is a rare event in the ICU setting and tends to occur in severely ill patients. H. pylori infection is more frequent in patients with gastroduodenal hemorrhage than in nonbleeding patients.

To determine the prognostic indicators of long-term survival after admission to a medical intensive care unit (MICU) for patients aged 80 years and over. DESIGN. Prospective cohort study.A 14-bed MICU in a 970-bed, acute care, tertiary, university hospital in Paris, France.A total of 233 patients aged 80 years and over discharged from a MICU during a 2-year period.Severity at admission was estimated using the Simplified Acute Physiology Score. The underlying condition was classified using the MacCabe classification. The functional status was assessed using the Knaus classification. The outcome after MICU discharge was determined after a median 2-year follow-up. The functional outcome was assessed by telephone interviews, employing the Instrumental Activities of Daily Living (IADL). The in-MICU mortality was 19.5% including death occurring during the 2 days following discharge. The long-term survival rates for patients admitted to the MICU were 59% at 2 months, 33% at 2 years, and 29% at 3 years. The multivariate analysis identified two prognostic factors of death after discharge: presence of an underlying fatal disease (HR 1.7; 95% CI 1.1-2.6) and severe functional limitation (HR 1.7; 95% CI 1.2-2.6). The IADL was excellent or good for 56% of the surviving patients.Long-term survival after MICU is mainly related to the underlying condition, whereas known factors for in-MICU survival do not influence long-term prognosis.

The presence of circulating endotoxin is common during sepsis but its prognostic value is poor. We hypothesized that this lack of correlation with outcome could be related in part to the presence of circulating antiendotoxin antibodies. In a 14-bed medical intensive care unit, in an 821-bed tertiary teaching hospital, we prospectively assessed endotoxin and antiendotoxin antibodies in patients with severe sepsis or septic shock. Blood samples for the determination of circulating endotoxin and antiendotoxin antibodies were drawn when severe sepsis or septic shock were diagnosed (day 0) and then on day 1, day 2, and day 4. Daily measurements of antiendotoxin antibodies did not discriminate survivors from nonsurvivors. No antibody depletion was observed. However, during follow-up, the antiendotoxin immunoglobulin (Ig)M antibody level increased among survivors but decreased among nonsurvivors (51.2 vs −44.8 MU/mL, P = .007). Circulating endotoxin was detectable among 9 of 17 patients on inclusion but neither the basal value nor sequential measurements correlated with outcome. These results suggest that during severe sepsis and septic shock, circulating endotoxin is a poor prognostic marker whereas the detection of an increase in IgM antiendotoxin antibody levels could identify survivors. This increase in IgM antibody levels could be attributed to a reactivation of the immune system. © Elsevier Inc. All rights reserved.

Life-threatening bleeding in four patients with an unusual excessive response to dabigatran: Implications for emergency surgery and resuscitation

Background In critically ill patients with pneumonia, accurate microorganism identification allows appropriate antibiotic treatment. In patients undergoing bronchoalveolar lavage (BAL), direct examination of the fluid using Gram staining provides prompt information but pathogen identification accuracy is low. Culture of BAL fluid is actually the reference, but it is not available before 24 to 48 h. In addition, pathogen identification rate observed with direct examination and culture is decreased when antibiotic therapy has been given prior to sampling. We therefore assessed, in critically ill patients with suspected pneumonia, the performance of a multiplex PCR (MPCR) to identify pathogens in BAL fluid. This study is a prospective pilot observation. Methods We used a MPCR detecting 20 types of microorganisms. Direct examination, culture, and MPCR were performed on BAL fluid of critically ill patients with pneumonia suspicion. The final diagnosis of infective pneumonia was retained after the medical chart was reviewed by two experts. Pathogen identification rate of direct examination, culture, and MPCR in patients with confirmed pneumonia was compared. Results Among the 65 patients with pneumonia suspicion, the diagnosis of pneumonia was finally retained in 53 cases. Twenty nine (55%) were community-acquired pneumonia and 24 (45%) were hospital acquired. Pathogen identification rate with MPCR (66%) was greater than with culture (40%) and direct examination (23%) (p =0.01 and p p p p Conclusions The results of this pilot study suggest that in critically ill patients, MPCR performed on BAL fluid could provide higher identification rate of pathogens involved in pneumonia than direct examination and culture, especially in patients having received antimicrobial treatment.

Study objectives To assess the characteristics and outcomes of patients admitted to an ICU for severe accidental hypothermia, and to identify risk factors for mortality. Methods All consecutive patients admitted to an ICU between January 1, 1979, and July 31, 1998, with a temperature of≤ 32°C were retrospectively analyzed. Rewarming was always conducted passively with survival blankets and conventional covers. Prognostic factors were studied by means of univariate analysis (Mann-Whitney U and χ 2 tests) and multivariate analysis (logistic regression). Results Forty-seven patients were enrolled (mean ± SD age, 61.7 ± 16 years). Five patients had a cardiac arrest before ICU admission. Patient characteristics at ICU admission were as follows: temperature, 28.8 ± 2.5°C; systolic BP, 85 ± 23 mm Hg; heart rate, 60 ± 24 beats/min; Glasgow Coma Scale, 10.4 ± 3.7; and simplified acute physiology score (SAPS) II, 50.9 ± 27. Mechanical ventilation was necessary in 23 cases, and 22 patients in shock received vasoactive drugs. The mean length of stay in the ICU was 6.7 ± 9 days. Eighteen patients (38%) died, but ventricular arrhythmia was never the cause. Univariate analysis identified several prognostic factors (p Conclusion Severe accidental hypothermia is a rare cause of ICU admission in an urban area. Its mortality remains high, but there is no overmortality according to the SAPS II-derived prediction of death. Shock, requiring treatment with vasoactive drugs, is an independent risk factor for mortality, while initial core temperature is not. It remains to be determined whether aggressive rather than passive rewarming procedures are better.

Objective: To identify parameters thatindicate retained secretions and the need for tracheal suctioning (TS)in patients receiving mechanical ventilation (MV). Design: Prospective observational study. Setting: A 14-bed medical ICU in a 946-bed universityhospital. Patients: Sixty-six consecutive patientsreceiving MV. Interventions: Two successive trachealsuctions, TS1 and TS2, performed at a 2-h interval as usual patientcare. Retained secretions were considered significant if the volume of secretions removed by TS2 was > 0.5 mL. Measurementsand results: Variations between TS1 and TS2 of pulse oximetricsaturation (Sp o 2 ), peak inspiratory pressure(Ppeak), tidal volume (V t ), and Ramsay score were comparedbetween patients with TS2 ≤ 0.5 mL (group 1; n = 27) and patientswith TS2 > 0.5 mL (group 2; n = 39). The presence of a sawtoothpattern on flow-volume loop displayed on the monitor screen of theventilator and of respiratory sounds heard over the trachea before TS2were compared between the two groups. Variations of Ppeak, V t , Sp o 2 , and Ramsay score betweenTS1 and TS2 did not differ between the two groups. However, group 2 hada sawtooth pattern (82% vs 29.6%; p = 0.0001) and respiratorysounds (66.6% vs 25.9%; p = 0.001) more frequently than group 1before TS2. For the sawtooth pattern, the likelihood ratio (LR) of apositive test was 2.70 and the LR of a negative test was 0.25, whilefor respiratory sounds it was 2.50 and 0.45, respectively. When thepresence of a sawtooth pattern and of respiratory sounds was combined, the LR of a positive test rose to 14.7 and the LR of a negative testwas 0.42. Conclusions: A sawtooth pattern and/orrespiratory sounds over the trachea are good indicators of retainedsecretions in patients receiving MV and may indicate the need for TS. Conversely, the absence of a sawtooth pattern may rule out retainedsecretions.

We investigated whether rubbing with an alcohol solution increases compliance with hand disinfection in a medical intensive care unit (MICU). During a first period (P1), hand disinfection was achieved only through conventional washing, whereas during a second period (P2), hand disinfection could be achieved either through conventional washing or rubbing with an alcohol solution. There were 621 opportunities for hand disinfection during P1 and 905 opportunities during P2. General compliance during P1 was 42.4%, and reached 60.9% during P2 (p < 0.001). This improvement was observed among nurses (45.3% versus 66.9%, p < 0.001), senior physicians (37. 2% versus 55.5%, p < 0.001), and residents (46.9% versus 59.1%, p = 0.03). Acceptability and tolerance were evaluated through the answers to an anonymous questionnaire distributed to all 53 health care workers in the MICU. Rubbing with alcohol solution was an easy procedure (100% of responses) and induced mild side effects in less than 10% of respondents. In a complementary study conducted 3 mo after the first one, compliance remained better than during P1 (51. 3% versus 42.4%, p = 0.007). These findings suggest that rubbing with alcohol solution increases compliance with hand disinfection, and that it could be proposed as an alternative to conventional handwashing in the MICU.

Objective— To study the role of Mer receptor tyrosine kinase (mertk) in atherosclerosis. Methods and Results— We irradiated and reconstituted atherosclerosis-susceptible C57Bl/6 low-density lipoprotein receptor-deficient female mice ( ldlr −/− ) with either a mertk +/+ or mertk −/− (tyrosine kinase-defective mertk) bone marrow. The mice were put on high-fat diet for either 8 or 15 weeks. Mertk deficiency led to increased accumulation of apoptotic cells within the lesions, promoted a proinflammatory immune response, and accelerated lesion development. Conclusions— Mertk expression by bone marrow-derived cells is required for the disposal of apoptotic cells and controls lesion development and inflammation.

Resume La necrose corticale renale bilaterale est une cause tres rare d'insuffisance renale aigue qui a ete surtout rapporte a des causes obstetricales dans les annees 1970. Nous rapportons ici le premier cas de necrose corticale bilaterale lie a un syndrome des antiphospholipides (SAPL) paraneoplasique.

Acute bilateral renal cortical necrosis is a very rare cause of acute renal failure. We report here for the first time a case related to antiphospholipid syndrome, paraneoplastic of a lung neoplasia. A 46-year-old male smoker without medical history was admitted for acute dyspnea and anuria. Biological examination showed acute renal failure associated with hyperkalemia, high serum lactate dehydrogenase level, and prolonged activated thrombin time (ratio 1.29). Chest radiograph showed a right laterotracheal round lesion. A percutaneous left renal biopsy showed cortical necrosis, and renal arteriography confirmed bilateral cortical necrosis. Blood examination showed antiphospholipid antibodies type anticardiolipin. Chest computed tomographic scan confirmed the presence of a lung tumor. Two years after tumor surgery, the patient was still anuric and on long-term hemodialysis therapy, but antiphospholipid antibody results were negative. This case describes the first association of antiphospholipid syndrome to epidermoid lung cancer, shown by cortical bilateral necrosis. It also emphasizes the utility of renal biopsy in case of an unusual acute renal failure.

The accumulation of hydroxyethyl starches (HES) in monocytes/macrophages has raised concern over their potential detrimental effects on host defences. We assessed prospectively the function of circulating monocytes isolated from patients treated with plasma exchange (PE) using HES. The study was carried out in the medical intensive care unit of a university hospital. Eight patients underwent PE for neurological disorders. Each patient underwent three PEs, 48 h apart. The total exchange volume was 4 L per PE. Only 4% human albumin was used for the first PE. In the second and third PEs, the plasma substitute was 2 L of HES (200,000/6%/0.62) and 2 L of albumin. Mononuclear cells were collected before and immediately after each PE and 48 h after the last PE. They were placed in suspension culture and incubated with lipopolysaccharide (LPS). Monocyte function was assessed in terms of procoagulant activity (PCA) and tumour necrosis factor alpha (TNF-alpha) production. LPS-stimulated PCA increased after the first PE (P < 0.05). Stimulated TNF-alpha production increased, but not significantly so. Similar effects were observed after the second and third PE (P < 0.05 for stimulated TNF-alpha). Values 48 h after the last PE were similar to those obtained before the second PE, suggesting that repeated infusions of HES had no detrimental effect on monocyte function. Furthermore, plasma oncotic pressure was preserved after PE with HES. These results support the partial replacement of costly human albumin with HES during repetitive PE, and suggest that HES might be a safe plasma expander in septic patients.

Resume La dyspnee laryngee (DL) est une complication redoutee de l'intubation tracheale. Le but de cette etude prospective est de preciser la frequence, les causes ainsi que les consequences de la DL chez des patients hospitalises en reanimation polyvalente. Tous les patients qui n'ont pas ete extubes dans le service ont ete exclus (n = 102 representant 36 p. 100 des patients intubes pendant la duree de l'etude). L'etude a inclus 178 patients evaluables sur une periode d'un an (âge 58,9 ± 18,5 ans ; IGS 13,4 ± 5,6 ; duree moyenne d'intubation 4,3 ± 4,1 jours). La DL, definie par une dyspnee inspiratoire survenant moins de 12 heures apres une extubation programmee, etait observee chez 13 patients (7,3 p. 100). Le risque de developper une DL augmente avec la duree d'intubation (7,2 ± 6,8 contre 4,1 ± 3,7 jours, p = 0,007) et peut-etre chez les patients obeses (pourcentage du poids ideal : 129,2 ± 35,3 contre 111,6 ± 31,4 ; p = 0,055). Douze des treize patients ont ete traites par corticotherapie intraveineuse. Six patients (46 p. 100) ont du etre reintubes rapidement. Cinq d'entre eux ont ete extubes definitivement 24 a 72 heures apres la premiere extubation et le sixieme a ete tracheotomise pour stenose tracheale serree. La fibroscopie laryngee a objective un œdeme local [severe n = 3, modere n = 9], des plaies muqueuses [n = 5]. La localisation des lesions etait sus-glottique [n = 2] glottique [n = 5], sous-glottique [n = 3], glottique et sous-glottique [n = 2]. Il y avait une stenose tracheale serree. Ce travail a permis de definir une population particulierement a risque de DL (duree prolongee d'intubation, surcharge ponderale) et de montrer l'absence de relation evidente entre les lesions anatomiques observees a la fibroscopie et la gravite de la DL (celle justifiant une reintubation precoce). Il permet d'envisager chez des patients a haut risque un protocole preventif comme un traitement corticoide institue 24 a 48 heures avant l'extubation

Resume Le choix d'un substitut du plasma est fonction de son efficacite macro- et microcirculatoire mais aussi de sa duree d'action, de sa tolerance et de son cout. Les cristalloides iso-osmotiques ont un pouvoir de remplissage 4 a 5 fois plus faible que les colloides. L'albumine humaine, colloide naturel, a un pouvoir de remplissage non superieur a certains dextrans ou hydroxyethyl amidons (HEA) et un prix qui justifie de limiter largement sa prescription. Parmi les colloides de synthese, les dextrans ont deux inconvenients principaux : des reactions allergiques et une modification de l'hemostase. Les gelatines n'ont pas de dose limite mais la duree d'action est breve, l'effet rheologique defavorable et les risques d'accidents allergiques plus eleves qu'avec les autres colloides. Les HEA de bas poids moleculaire, ont une duree d'action modulable en fonction de leur vitesse de decoupage intravasculaire, un effet favorable sur la microcirculation et un faible risque allergique. Leur neutralite vis-a-vis de l'hemostase est demontree a concurrence de 30 ml/kg. Les cristalloides hypertoniques constituent une categorie a part avec une expansion volemique de courte duree mais un effet sur la contractilite cardiaque et la vasomotricite. Les solutions associant colloides et cristalloides hypertoniques sont en cours d'evaluation. Le risque de constitution ou d'aggravation d'œdemes peripheriques et surtout pulmonaire est a prendre en consideration lors de la realisation du remplissage vasculaire. En fait, lorsque la membrane capillaire pulmonaire est intacte, le poumon est longtemps protege grâce a sa richesse en lymphatiques et sa capacite a maintenir un gradient oncotique transcapillaire. Cependant, une baisse majeure de pression oncotique plasmatique entraine une baisse du seuil de pression hydrostatique tolerable. Lorsque la membrane est alteree, c'est surtout le controle de la pression hydrostatique qui limite la formation d'œdeme pulmonaire. Ainsi, quelque soit l'etat de la membrane alveolo-capillaire, l'albumine n'a pas d'avantage par rapport aux autres colloides. En conclusion, l'objectif du traitement de l'hypovolemie est de retablir au plus vite l'adequation entre apports et besoins en oxygene. Le choix du substitut du plasma doit tenir compte de la reponse hemodynamique au remplissage, de la tolerance et du cout. Dans ces conditions, l'albumine doit avoir une place tres limitee.

Resume Le but de ce travail etait d'evaluer trois facteurs capables d'influencer l'impact d'une Conference de Consensus. La Conference de Consensus etudiee etait la TVe Conference de Consensus de la SRLF. Un questionnaire adresse a tous les membres de la SRLF et de la Societe Francaise d'Anesthesie-Reanimation (SFAR) avait pour but d'etudier : -- la connaissance de l'existence de la Conference de Consensus par les membres de ces societes, -- leur connaissance du contenu des recommandations formulees par le jury (a partir d'un echantillon de huit recommandations), -- leur adhesion theorique a ces recommandations (a partir d'un echantillon de six recommandations). Quatre-vingt-onze pour cent des medecins interroges avaient connaissance de la Conference de Consensus. Cette connaissance etait acquise pour la majorite d'entre eux d'abord par la lecture du resume recu personnellement (59 p. 100), suivie de pres par la lecture du texte integral dans la revue de la SRLF (57,5 p. 100) et enfin par la lecture du resume dans une autre revue (26 p. 100). Le contenu des huit recommandations testees par le questionnaire etait connu de 66 a 93 p. 100 des medecins interroges. Leur adhesion theorique aux six recommandations testees variait de 66,5 p. 100 a 93 p. 100. L'etude de la connaissance des recommandations d'une Conference de Consensus et de l'adhesion theorique a ces recommandations dans un exemple representatif des medecins les plus concernes par le sujet pourrait aider a analyser l'impact d'une Conference de Consensus, a detecter les raisons d'un impact insuffisant et a ameliorer les resultats definitifs d'une Conference de Consensus. Certains des enseignements de telles etudes pourraient etre appliques lors de l'organisation de Conferences de Consensus ulterieures.

SummaryThe aim of the study was to identify the predictors of brain death (BD) uponadmission to the intensive care unit (ICU) of comatose patients with spontaneousintracerebral hemorrhage (ICH). Patients admitted in our ICU from 2002 to 2010for spontaneous ICH and placed under mechanical ventilation were retrospec-tively analyzed. Of the 72 patients, 49% evolved to BD, 39% died after withdrawalof life support, and 12% were discharged alive. The most discriminating charac-teristics to predict BD were included in two models; Model 1 contained 3 abol-ished brainstem responses [adjusted odds ratios (OR) = 8.4 (2.4, 29.1)] and theswirl sign on the baseline CT-scan [adjusted OR = 5.0 (1.6, 15.9)] and Model 2addressed the abolition of corneal reflexes [unilateral/bilateral: adjusted OR = 4.2(0.9, 20.1)/8.8 (2.4, 32.3)] and the swirl sign on the baseline CT-scan [adjustedOR = 6.2 (1.9, 20.0)]. Two scores predicting BD were created (sensitivity: 0.89and 0.88, specificity: 0.68 and 0.65). Risk of evolution toward BD was classified aslow (corneal reflexes present and no swirl sign), high ( 1 corneal reflexes abol-ished and swirl sign), and intermediate. Simple signs at ICU admission can pre-dict BD in comatose patients with ICH and could increase the potential for organdonation.IntroductionEarly prediction of evolution toward brain death (BD) incomatose patients with stroke is of great interest as BD iscurrently in France the primary source of organ donation(80%) [1,2]. Recently, the recommendations of Frenchsocieties regarding stroke management outlined that coma-tose patients with stroke and very bad prognosis could ethi-cally be admitted to ICU if evolution toward BD, allowinga potential organ donation, seems likely [3]. However, todate, no accurate criteria predicting evolution toward BDin comatose patients with stroke has been reported.Spontaneous intracerebral hemorrhage (ICH) is thedeadliest type of stroke and is a leading cause of mortalityand morbidity worldwide [4–7]. The two main causes ofdeath after ICH admitted to ICU are withdrawal of life sup-port for perceived futility of care and BD [8–10]. Althoughmany studies have evaluated early predictors of neurologi-cal outcomes after ICH, none specifically sought to iden-tify predictors of BD. Most of these studies pooled the

Study objectives To study circulatory endotoxin (ET) in patients with sepsis syndrome ( SS ) in order to answer three questions: (a) How often and at which concentration is ET present in the plasma of patients with SS and is the presence of ET a prognostic marker in this situation? (b) Is detection of ET helpful in predicting Gram-negative bacterial infections with or without bacteremia? (c) What are the kinetics of clearance of ET concentrations in plasma? Design Prospective study of consecutive patients fulfilling Bone's criteria for SS. Setting Medical ICU in a teaching hospital. Patients The study included 93 patients. The simplified acute physiologic score was 19±6, 49 percent were in shock, and 54 percent were mechanically ventilated. The mortality at day 28 was 53 percent. Measurements Endotoxin determinations and blood cultures were performed simultaneously at the onset (day 1) of SS. Samples were collected on several days from 48 patients. Endotoxin concentration was determined using an end point chromogenic Limulus assay. For the first ET determination, the mean circulatory level (mean±SEM) was calculated among patients with detectable ET, thus excluding patients with a null value for ET. Results On day 1, ET was detected in 44 patients (47 percent; 60.2±16.5 pg/ml) and was statistically more frequent in patients with shock, elevated plasma lactate, and organ failure. There was no statistical difference for age, gender, ratio of PaO 2 to fraction of inspired oxygen. Among patients with proven Gram-negative bacterial infection (n = 46), ET was detected in 67 percent as compared with 28 percent without Gram-negative bacterial infection (p = 0.0001). On day 1, among 19 patients who had positive blood cultures with Gram-negative bacteria (GNB), 15 had detectable ET (79 percent, 61±22 pg/ml). In 14 other patients whose blood cultures were positive for GNB but became negative on day 1, 9 had detectable ET (64 percent; 36±6.5 pg/ml). Endotoxin declined linearly between days 1 and 4. Conclusion In our study, the plasma ET concentration predicts neither Gram-negative infection, with or without bacteremia, nor the outcome. However, when ET is present in the plasma of patients with SS it remains detectable for a long period of time as compared to its rapid disappearance from plasma of animals or healthy human volunteers receiving ET intravenously. This slow clearance of ET suggests either a continuous release or a defect in its clearance.

The presence of a femoral venous catheter could be associated with gas presence in the hepatic veins. This entity should be recognized to avoid a misdiagnosis of gas presence in the portal veins or in the biliary tract. Objectives are to assess: 1) the incidence of gas presence in the hepatic veins in intensive care unit patients explored by abdominal computed tomography scan; 2) the rate of gas presence in the liver in intensive care unit patients with a catheter inserted in the femoral vein; and 3) the specific imaging features.A retrospective study in a medical intensive care unit in a teaching hospital in France.All consecutive abdominal computed tomography scans performed in intensive care unit patients between 2008 and 2010 were retrospectively reviewed independently by an intensivist and a radiologist. Presence of gas in the liver was noticed and its location was specified using multiplanar reconstruction.We analyzed 235 computed tomography scans (performed in 207 patients). Gas was identified in the liver on 10.2% of computed tomography scans. Gas was located in the hepatic veins in 12 cases (50%), in the biliary tract in ten cases (41.7%), and in the portal veins in two cases (8.3%). All patients with gas in the hepatic veins had a femoral venous catheter. Characteristics of gas location within the hepatic veins on computed tomography scan axial views were not different from those of gas located in the biliary tract or in the portal venous system. Gas was present in the hepatic veins in 12 of 83 (14.5%) of the computed tomography scans with a femoral venous catheter and was associated with gas presence in other vessels of the inferior vena cava system in five of 12 (41.7%) cases.Gas located in the hepatic veins related to femoral venous catheter is a frequent cause of gas in the liver in intensive care unit patients. This imaging feature could be misleading. Multiplanar reconstruction should be performed to differentiate this aspect from those of gas in the biliary tract or in the portal venous system.

Severe infections caused by hypermucoviscous Klebsiella pneumoniae have been reported in Southeast Asian countries over the past several decades. This report shows their emergence in France, with 12 cases observed during a 2-year period in two university hospitals. Two clones (sequence type 86 [ST86] and ST380) of serotype K2 caused five rapidly fatal bacteremia cases, three of which were associated with pneumonia, whereas seven liver abscess cases were caused by K1 strains of ST23.

The mortality rate among patients with human immunodeficiency virus (HIV) requiring mechanical ventilation (MV) for acute respiratory failure (ARF) secondary to Pneumocystis carinii pneumonia (PCP) is still a matter of discussion. For some authors, it is in the 50 percent range, while for others the prognosis is grim, with virtually no survivors. The aim of this retrospective study conducted between January 1987 and January 1992 was to analyze the outcome of such patients. We studied 33 patients, 29 men and 4 women (38.6 +/- 9.9 years, 21 homosexuals, 8 intravenous drug users, 3 transfusion related, 1 heterosexual) infected by HIV for at least 19.7 +/- 21.6 months. It was the first PCP episode in all but 2 patients and the diagnosis was made by bronchoalveolar lavage (n = 32) or lung biopsy specimen (n = 1). Only three patients were receiving primary prophylaxis for PCP (trimethoprim-sulfamethoxazole [TMP-SMZ], n = 2; pentamidine, n = 1). Pneumocystis carinii pneumonia was the first manifestation of AIDS in nine patients. The duration of symptoms prior to treatment was 19.6 +/- 11.3 days. At the time of hospital admission, laboratory findings were as follows: PaO2 = 40.7 +/- 7.8 mm Hg on room air; serum LDH = 1,172 +/- 792 IU/L; T4 cell count = 60.2 +/- 67/mm3. Mechanical ventilation was always required for ARF, which was never induced by bronchoscopy. The interval between treatment and MV was 8.1 +/- 6.5 days and the duration of MV was 11.4 +/- 9.9 days. The patients were classified into 3 groups on the basis of the duration and type of treatment before MV, as follows: group 1, n = 10: TMP-SMZ (20-100 mg/kg) IV and methylprednisolone (MP) or = 5 days and MP or = 5 days before MV. (The MP dose was as follows: 240 mg/d once a day from day 1 to day 3; 120 mg/d from day 4 to day 6; and 60 mg/d from day 7 to day 9.) Despite MV, TMP-SMZ, and MP, death secondary to PCP-related ARF occurred in 81.9 percent of patients, 20 +/- 4.8 days after the beginning of treatment and 11.4 +/- 9.9 days after the beginning of MV. Six patients survived, five in group 1 and one in group 3.(ABSTRACT TRUNCATED AT 400 WORDS)

Resume Les etats infectieux graves s'accompagnent de modifications metaboliques et de liberation de cytokines. Les rapports entre ces deux modifications sont complexes et il y a peu d'arguments directs permettant de rapporter a une cytokine donnee un effet metabolique precis. Les interactions des cytokines entre elles et avec les autres mediateurs ainsi que la stimulation concomitante des systemes neuro-hormonaux qui exercent leurs propres effets metaboliques rendent difficile l'appreciation du role exact de chaque cytokine dans la genese des desordres metaboliques. Ainsi, des effets decrits avec des surnageants de cultures de macrophages n'ont pu etre reproduit avec des cytokines recombinantes. Parmi les cytokines, le TNF, l'IL-1 et IL-6 ont surtout ete etudies dans les etats infectieux graves. TNF et IL-1 augmentent les depenses energetiques. L'IL-6 induit la formation hepatique des proteines de la phase aigue. TNF et IL-1 augmentent les hormones glucoformatrices et favorisent la neoglucogenese. Les glucocorticoides expliquent en partie l'effet proteolytique du TNF et de l'IL-1. TNF et IL-1 activent la lipogenese hepatique ce qui explique partiellement l'hyperlipidemie observee dans les etats infectieux graves. Compte tenu des incertitudes persistantes, les traitements anticytokines visant a controler l'agression metabolique observee dans les etats infectieux graves ne peuvent pas etre recommandees en pratique clinique.

We evaluated ultrasonic examination as a diagnostic tool for catheter misplacement and pneumothorax after central venous catheter insertion. Physicians in the intensive care unit (ICU) performed the ultrasonic examinations, and the results were compared with those of chest radiography. Eighty-five central venous catheters (70 subclavian and 15 internal jugular) were inserted into 81 patients; 10 misplacements and one pneumothorax occurred. Ultrasonic examination feasibility was 99.6%. The only pneumothorax and all misplacements except one were diagnosed by ultrasound. Taking into consideration misplacements and pneumothorax research, ultrasonic examination did not give any false positive results. The mean time of the entire ultrasonic examination was 6.8 +/- 3.5 min, whereas 80.3 +/- 66.7 min were needed for the radiography (p < 0.0001). This study has suggested that ultrasonic diagnosis of catheter misplacement and pneumothorax related to central venous catheterization is a rapid and accurate method that can be easily performed by ICU physicians.

Objectives: To reassess the prognosis of patients with cirrhosis admitted to the intensive care unit. Design: A retrospective study in a medical intensive care unit in a teaching hospital in France. Patients: All patients with cirrhosis without previous liver transplantation admitted in the period from 2005 to 2008. Interventions: None. Main Results: One hundred thirty-eight patients were studied. Survival rates in the intensive care unit, in hospital, and at 6 months were 59% (95% confidence interval, 50%‐67%), 46% (95% confidence interval, 38%‐54%), and 38% (95% confidence interval, 30%‐ 47%), respectively. In-hospital survival rates for patients requiring vasopressors, mechanical ventilation, or renal replacement therapy were 20%, 33%, and 31%, respectively. On day 1, independent risk factors for inhospital mortality were age, albuminemia, international normalized ratio, and the Sequential Organ Failure Assessment score computed after discarding points for hematologic failure (modified Sequential Organ Failure Assessment score). Liver disease severity, assessed using a clinical classification, did not correlate with inhospital mortality. In patients still alive after 3 days, the only prognostic factor was the modified Sequential Organ Failure Assessment score computed after 3 days. To predict inhospital mortality, the modified Sequential Organ Failure Assessment score on day 1 had a greater area under the receiver operating characteristic curve (0.84) than the Simplified Acute Physiology Score II (0.78), the Child-Pugh score (0.76), the model for end-stage liver disease score (0.77), or the model for end-stage liver disease‐natremia score (0.75). The inhospital mortality rate with three or four nonhematologic organ failures on day 1 was not >70%, whereas it was 89% with three nonhematologic organ failures after 3 days spent in the intensive care unit. Conclusion: In-hospital survival rate of intensive care unitadmitted cirrhotic patients seemed acceptable, even in patients requiring life-sustaining treatments and/or with multiple organ failure on admission. The most important risk factor for inhospital mortality was the severity of nonhematologic organ failure, as best assessed after 3 days. A trial of unrestricted intensive care for a few days could be proposed for select critically ill cirrhotic patients. (Crit Care Med 2010; 38:2108‐2116)

Radiography is the criterion standard method to ensure correct placement of a feeding tube. Recently, excellent results were reported using a combination of colorimetric capnography and epigastric auscultation, but the impact of this technique has not been studied to date. Objectives were to assess whether our local procedure, using colorimetric capnography to ensure proper feeding tube placement, improves the patient's care, satisfies nurses, and decreases costs compared with the standard procedure requiring systematic radiography.We performed a monocentric prospective observational study in a medical intensive care unit over a 4-month period. Feeding tube placement was assessed by colorimetric capnography and epigastric auscultation. Radiography was performed when epigastric auscultation was inconclusive.A total of 69 feeding tubes were placed in 44 patients. Radiography was required in 10.1% of the cases. The new procedure decreased costs ($33.37 ± 13.96 vs $45.92, P.0001) and was less time consuming (11.6 ± 20.5 minutes vs 87.3 ± 45.2 minutes, P.0001) than using systematic radiography. All nurses reported confidence in the procedure, which improved the organization of their care.The use of colorimetric capnography and epigastric auscultation to confirm feeding tube placement improves nurse's organization of care, saves time, and decreases costs.

Background Pleural ultrasonography (PU) is more sensitive than chest radiograph (CXR) for diagnosing pneumothorax and could be useful for detecting resolution of pneumothorax after drainage. The aim of this prospective double-blind observational study was to assess PU accuracy during pneumothorax follow-up after drainage. Methods All patients hospitalized with pneumothorax requiring drainage were eligible. After drainage, residual pneumothorax was assessed by CXR and PU (1) 24 h after bubbling in the aspiration device had stopped, (2) 6 h after clamping the pleural catheter, and (3) 6 h after removing the pleural catheter. Pneumothorax indicated by PU but not CXR was confirmed by CT scan or by aspiration of > 10 mL of air. Results Forty-four unilateral pneumothoraces were studied (primary spontaneous: 70.5%), and 162 pairs of examinations (CXR and PU) were performed. Twenty residual pneumothoraces were detected by both CXR and PU. Furthermore, PU suspected 14 pneumothoraces that were not identified by CXR; 13 were confirmed. All of these pneumothoraces resulted in therapeutic intervention. Thus, 39% (13/33) of the confirmed residual pneumothoraces were missed by CXR. In patients with primary spontaneous pneumothorax, the positive predictive value of PU for residual pneumothorax diagnosis was 100%; for other pneumothoraces, this value ranged from 90% in the absence of a lung point to 100% when a lung point was observed. PU results were obtained faster than results from CXR (35 ± 34 min vs 71 ± 56 min, P Conclusions The accuracy of PU is excellent for detecting residual pneumothorax during pneumothorax follow-up after drainage.

Resume Objectif Estimation de l'impact au sein des membres de la SRLF des conclusions de la conference de consensus (CC) consacree a la prevention des hemorragies gastroduodenales (HGDS). Methode Realisation de deux enquetes successives, l'une precedant, l'autre suivant la CC, au moyen d'un questionnaire preetabli adresse a tous les membres de la SRLF faisant preciser leurs modalites de prevention utilisees et la frequence des HGDS dans leurs services. Resultats Pour la premiere enquete, 125 reponses ont ete obtenues, 86 pour la seconde. Les deux enquetes sont comparables pour ce qui concerne les principales caracteristiques des deux populations, la prevalence et la gravite des HGDS. Dans les deux enquetes, la prevention des HGDS est peu utilisee de facon systematique (16 et 17 % des reponses), et reste reservee a des groupes a risque (51 et 52 %). Dans la seconde enquete, 85 % des medecins declarent connaitre les conclusions de la CC. La proportion de medecins interroges utilisant les cytoprotecteurs seuls comme traitement preventif des HGDS en accord avec les conclusions du consensus, passe de 10 % en 1988 a 52 % en 1990. La meme augmentation est observee chez les 32 medecins qui ont repondu aux deux enquetes : 10 % en 1988, 52 % en 1990. Conclusions : Malgre le nombre eleve de donnees manquantes, ce travail suggere que la CC est suivie d'un impact sensible sur les intentions de prescription des medecins de la SRLF.

The endothelium is a highly dynamic cell layer that is involved in a multitude of physiological functions, including the control of vascular tone, the movement of cells and nutrients, the maintenance of blood fluidity and the growth of new vessels. During severe sepsis, the endothelium becomes proadhesive, procoagulant, antifibrinolytic and is characterized by alterations of vasomotor regulation. Most of these functions have been discovered using in vitro and animal models, but in vivo exploration of endothelium in patients remains difficult. New tools to analyze endothelial dysfunction at bedside have to be developed.

Herpes simplex virus hepatitis (HSV hepatitis) is an uncommon and severe complication of HSV type 1 and HSV type 2 infection. HSV hepatitis affects mostly immunocompromised patients. We report the case of a young man without any previous known immunodeficiency who developed fatal HSV hepatitis in the first 8 days of oral corticotherapy given for ulcerative colitis. A prompt diagnosis was possible because HSV was recovered from peripheral blood leukocytes.

To evaluate limited training of ICU physicians without knowledge of ultrasound in performing basic general ultrasonography.A prospective, observational, study conducted in a 14-bed MICU.Seventy-seven critically ill patients (38 females) aged 64 +/- 16 years, with a SAPS II score of 47 +/- 21, 49 of whom (64%) were receiving mechanical ventilation.After 8.5 h of training comprising a 2.5 h didactic course that included essential views of normal and pathologic conditions and three hands-on sessions of 2 h each, one of eight ICU residents and the radiologist on duty performed the same examination in a blind manner. The questions addressed concerned the presence of pleural effusion, intra-abdominal effusion, acute cholecystitis, intrahepatic biliary duct dilation, obstructive uropathy, chronic renal disease, and deep venous thrombosis.The answers to 129 questions were analyzed. The possible presence of pleural effusion, and arguments for the presence of urinary tract obstruction and chronic renal insufficiency, were the questions most frequently addressed. Residents answered 84.4% of the questions correctly [Kappa: 0.66, CI 95% (0.32-1.12)]. Most of the discrepancies concerned small non-drainable pleural or abdominal effusions. For questions with a potential therapeutic impact, residents answered 95% of the questions correctly [Kappa 0.86, CI 95% (0.75-1.04)]. Residents completed the examination in 37 +/- 39 min compared with 296 +/- 487 min for the radiologists (P = 0.004).These results suggest that after brief focused training, intensive-care unit physicians without previous knowledge of ultrasonography can competently perform basic general ultrasonic examinations.

The aims of this study were to compare the antibacterial efficacy of handrubbing with an alcoholic rinse (AHRR) and two different alcoholic gels (AHRG) in reducing hand contamination under practical use conditions. We wanted to assess the acceptability of the three products and to determine the effect of each product on overall hand hygiene compliance. A prospective alternating time-series clinical trial was performed in a medical intensive care unit. The study was divided into three six-week periods (P1, P2, P3). Handrubbing was achieved with Sterillium rinse (AHRR) during P1, sterillium gel(AHRG-1) during P2 and Manugel Plus (AHRG-2) during P3. Pre- and post-rubbing hand contaminations were assessed immediately after a direct contact with a patient, using the glove juice technique. Health care workers (HCWs) evaluated the acceptability of the products through a self-administered anonymous questionnaire. Compliance of HCWs with hand hygiene was assessed during the three periods. We studied 242 handrubbing opportunities. The mean reduction factor (expressed as the Log(10) CFU/mL) of the AHRR, AHRG-1 and AHRG-2 were 1.28+/-0.95, 1.29+/-0.84 and 0.51+/-0.73, respectively (p0.001). Assessment of the three products by HCWs indicated that AHRR and AHRG-1 were significantly better accepted than AHRG-2. The overall compliance of HCWs to hand hygiene was better when gel was available. Under practical use conditions, AHRG-1 and AHRR were more effective than AHRG-2, although all were claimed to pass the European standard EN1500. In vivo trials are essential to compare the antimicrobial efficacy of products for handrubbing.

Health care systems stem from specific political, historical, cultural, and socioeconomic traditions. As a result, the organizational arrangements for health care differ considerably between Member States of the European Union. Health care in the European Union is at a crossroads between challenges and opportunities. The Member States are facing common challenges in delivering equal, efficient, and high-quality health services at affordable cost in times when the amount of care to be delivered is starting to exceed the resource base.