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BackgroundLittle is known on the burden of ICU care for stroke patients. The aim of this study was to provide a description of management strategies, resource use, complications and their association with prognosis of stroke patients admitted to ICU.MethodsUsing a population-based stroke registry, we analyzed consecutive stroke patients admitted to 3 ICU with at least one organ failure between 2008 and 2017. The study period was divided into two periods corresponding to the arrival of mechanical reperfusion technique.Predictors of ICU mortality were separately assessed in two multivariable logistic regression models, a “clinical model” and an “intervention model”. The same analysis was performed for predictors of functional status at hospital discharge.Results215 patients were included. Stroke etiology was ischemia in 109 patients (50.7%) and hemorrhage in 106 patients (49.3%). Median NIHSS score was 20.0 (9.0; 40.0). The most common reason for ICU admission was coma (41.2%) followed by acute circulatory failure (41%) and respiratory failure (27.4%). 112 patients (52%) died in the ICU and 20 patients (11.2%) had a good functional outcome (mRS≤3) at hospital discharge.In the “clinical model,” factors independently associated with ICU mortality were: age (OR = 1.03 [95%CI, 1.0 to 1.06];p=0.04) and intracranial hypertension (OR = 6.89 [95%CI, 3.55 to 13.38];p). In the “intervention model,” the need for invasive mechanical ventilation (OR = 7.39 [95%CI, 1.93 to 28.23];p=0.004), the need for vasopressor therapy (OR = 3.36 [95%CI, 1.5 to 7.53];p=0.003) and decision of withholding life support treatments (OR = 19.24 [95%CI, 7.6 to 48.65];p) were associated with bad outcome.ConclusionOur study showed the very poor prognosis of acute stroke patients admitted to ICU. These results also suggest that the clinical evolution of these patients during ICU hospitalization may provide important information for prognostication.

To describe early electrocardiogram (ECG) abnormalities after status epilepticus (SE) and evaluate their association with 90-day neurological outcomes.Retrospective analysis of a multicenter, national prospective registry between February 2018 and June 2020.Sixteen ICUs in France, IctalGroup Research Network.Adults with available ECG performed less than or equal to 24 hours after the onset of SE and less than or equal to 12 hours after its resolution.Double-blinded review of all ECGs was performed by two independent cardiologists. ECGs were categorized as normal/abnormal and then with minor/major early ECG abnormalities according to the Novacode ECG Classification system.Among 155 critically ill patients with SE, early ECG abnormalities were encountered in 145 (93.5%), categorized as major in 91 of 145 (62.8%). In addition to sinus tachycardia, the main abnormalities were in the ST segment (elevation [16.6%] or depression [17.9%]) or negative T waves (42.1%). Major early ECG abnormalities were significantly associated with respiratory distress and sinus tachycardia at the scene and hyperlactatemia at ICU admission. By multivariable analysis, three variables were significantly associated with 90-day poor outcome: age, preexisting ultimately fatal comorbidity, and cerebral insult as the cause of SE. Early major ECG abnormalities were not independently associated with 90-day functional outcome.In our study, early ECG abnormalities in the acute phase of SE were frequent, often unrecognized and were associated with clinical and biological stigma of hypoxemia. Although they were not independently associated with 90-day functional outcome, ECG changes at the early stage of SE should be systematically evaluated.Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03457831.

Severely ill patients affected by coronavirus disease 2019 (COVID-19) develop circulatory failure. We aimed to report patterns of left and right ventricular dysfunction in the first echocardiography following admission to intensive care unit (ICU).Retrospective, descriptive study that collected echocardiographic and clinical information from severely ill COVID-19 patients admitted to 14 ICUs in 8 countries. Patients admitted to ICU who received at least one echocardiography between 1st February 2020 and 30th June 2021 were included. Clinical and echocardiographic data were uploaded using a secured web-based electronic database (REDCap).Six hundred and seventy-seven patients were included and the first echo was performed 2 [1, 4] days after ICU admission. The median age was 65 [56, 73] years, and 71% were male. Left ventricle (LV) and/or right ventricle (RV) systolic dysfunction were found in 234 (34.5%) patients. 149 (22%) patients had LV systolic dysfunction (with or without RV dysfunction) without LV dilatation and no elevation in filling pressure. 152 (22.5%) had RV systolic dysfunction. In 517 patients with information on both paradoxical septal motion and quantitative RV size, 90 (17.4%) had acute cor pulmonale (ACP). ACP was associated with mechanical ventilation (OR 4), pulmonary embolism (OR 5) and increased PaCOAlmost one-third of this cohort of critically ill COVID-19 patients exhibited abnormal LV and/or RV systolic function in their first echocardiography assessment. While LV systolic dysfunction appears similar to septic cardiomyopathy, RV systolic dysfunction was related to pressure overload due to positive pressure ventilation, hypercapnia and pulmonary embolism. ACP and age seemed to be associated with mortality in this cohort.

IntroductionStatus epilepticus (SE) is a common life-threatening neurological emergency that can cause long-term impairments. Overall outcomes remain poor. Major efforts are required to clarify the epidemiology of SE and the determinants of outcomes, thereby identifying targets for improved management.Methods and analysisICTAL Registry is a multicentre open cohort of critically ill patients with convulsive, non-convulsive or psychogenic non-epileptic SE. Observational methods are applied to collect uniform data. The goal of the ICTAL Registry is to collect high-quality information on a large number of patients, thereby allowing elucidation of the pathophysiological mechanisms involved in mortality and morbidity. The registry structure is modular, with a large core data set and the opportunity for research teams to create satellite data sets for observational or interventional studies (eg, cohort multiple randomised controlled trials, cross-sectional studies and short-term and long-term longitudinal outcome studies). The availability of core data will hasten patient recruitment to studies, while also decreasing costs. Importantly, the vast amount of data from a large number of patients will allow valid subgroup analyses, which are expected to identify patient populations requiring specific treatment strategies. The results of the studies will have a broad spectrum of application, particularly given the multidisciplinary approach used by the IctalGroup research network.Ethics and disseminationThe ICTAL Registry protocol was approved by the ethics committee of the French Intensive Care Society (#CE_SRLF 19-68 and 19-68a). Patients or their relatives/proxies received written information to the use of the retrospectively collected and pseudonymised data, in compliance with French law. Prospectively included patients receive written consent form as soon as they recover decision-making competency; if they refuse consent, they are excluded from the registry. Data from the registry will be disseminated via conference presentations and peer-reviewed publications.Trial registration numberNCT03457831.

RATIONALE Whereas non-invasive ventilation (NIV) may prevent reintubation in patients at high-risk of extubation failure in intensive care units (ICUs), this oxygenation strategy has not been specifically assessed in obese patients. OBJECTIVES We hypothesized that NIV may decrease the risk of reintubation in obese patients compared with high-flow nasal oxygen (HFNO). METHODS Post-hoc analysis of a multicenter, randomized, controlled trial (not pre-specified) comparing NIV alternating with HFNO versus HFNO alone after extubation, with the aim of assessing NIV effects according to patient body-mass index (BMI). MEASUREMENTS AND MAIN RESULTS Among 623 patients at high-risk of extubation failure, 206 (33%) were obese (BMI≥30 kg/m2), 204 (33%) were overweight (25≤BMI

Summary Background Awake prone positioning has been reported to improve oxygenation for patients with COVID-19 in retrospective and observational studies, but whether it improves patient-centred outcomes is unknown. We aimed to evaluate the efficacy of awake prone positioning to prevent intubation or death in patients with severe COVID-19 in a large-scale randomised trial. Methods In this prospective, a priori set up and defined, collaborative meta-trial of six randomised controlled open-label superiority trials, adults who required respiratory support with high-flow nasal cannula for acute hypoxaemic respiratory failure due to COVID-19 were randomly assigned to awake prone positioning or standard care. Hospitals from six countries were involved: Canada, France, Ireland, Mexico, USA, Spain. Patients or their care providers were not masked to allocated treatment. The primary composite outcome was treatment failure, defined as the proportion of patients intubated or dying within 28 days of enrolment. The six trials are registered with ClinicalTrials.gov , NCT04325906 , NCT04347941 , NCT04358939 , NCT04395144 , NCT04391140 , and NCT04477655 . Findings Between April 2, 2020 and Jan 26, 2021, 1126 patients were enrolled and randomly assigned to awake prone positioning (n=567) or standard care (n=559). 1121 patients (excluding five who withdrew from the study) were included in the intention-to-treat analysis. Treatment failure occurred in 223 (40%) of 564 patients assigned to awake prone positioning and in 257 (46%) of 557 patients assigned to standard care (relative risk 0·86 [95% CI 0·75−0·98]). The hazard ratio (HR) for intubation was 0·75 (0·62−0·91), and the HR for mortality was 0·87 (0·68−1·11) with awake prone positioning compared with standard care within 28 days of enrolment. The incidence of prespecified adverse events was low and similar in both groups. Interpretation Awake prone positioning of patients with hypoxaemic respiratory failure due to COVID-19 reduces the incidence of treatment failure and the need for intubation without any signal of harm. These results support routine awake prone positioning of patients with COVID-19 who require support with high-flow nasal cannula. Funding Open AI inc, Rice Foundation, Projet Hospitalier de Recherche Clinique Interregional, Appel d'Offre 2020, Groupement Interregional de Recherche Clinique et d'Innovation Grand Ouest, Association pour la Promotion a Tours de la Reanimation Medicale, Fond de dotation du CHRU de Tours, Fisher & Paykel Healthcare Ltd.

We aimed to study the association of body temperature and other admission factors with outcomes of herpes simplex encephalitis (HSE) adult patients requiring ICU admission. We conducted a retrospective multicenter study on patients diagnosed with HSE in 47 ICUs in France, between 2007 and 2017. Fever was defined as a body temperature higher or equal to 38.3 °C. Multivariate logistic regression analysis was used to identify factors associated with poor outcome at 90 days, defined by a score of 3–6 (indicating moderate-to-severe disability or death) on the modified Rankin scale. Overall, 259 patients with a score on the Glasgow coma scale of 9 (6–12) and a body temperature of 38.7 (38.1–39.2) °C at admission were studied. At 90 days, 185 (71%) patients had a poor outcome, including 44 (17%) deaths. After adjusting for age, fever (OR = 2.21; 95% CI 1.18–4.16), mechanical ventilation (OR = 2.21; 95% CI 1.21–4.03), and MRI brain lesions > 3 lobes (OR = 3.04; 95% CI 1.35–6.81) were independently associated with poor outcome. By contrast, a direct ICU admission, as compared to initial admission to the hospital wards (i.e., indirect ICU admission), was protective (OR = 0.52; 95% CI 0.28–0.95). Sensitivity analyses performed after adjustment for functional status before admission and reason for ICU admission yielded similar results. In HSE adult patients requiring ICU admission, several admission factors are associated with an increased risk of poor functional outcome. The identification of potentially modifiable factors, namely, elevated admission body temperature and indirect ICU admission, provides an opportunity for testing further intervention strategies.

IntroductionThe use of sedation in intensive care units (ICUs) is necessary and ubiquitous. The impact of sedation strategy on outcome, particularly when delivered early after initiation of mechanical ventilation, is unknown. Evidence is increasing that volatile anaesthetic agents could be associated with better outcome. Their use in delirium prevention is unknown.Methods and analysisThis study is an investigator-initiated, prospective, multicentre, two-arm, randomised, control, open-trial comparing inhaled sedation strategy versus intravenous sedation strategy in mechanically ventilated patients in ICU. Two hundred and fifty patients will be randomly assigned to the intravenous sedation group or inhaled sedation group, with a 1:1 ratio in two groups according to the sedation strategy. The primary outcome is the occurrence of delirium assessed using two times a day confusion assessment method for the ICU (CAM-ICU). Secondary outcomes include cognitive and functional outcomes at 3 and 12 months.Ethics and disseminationThe study has been approved by the Regional Ethics Committee (CPP Ouest) and national authorities (ANSM). The results will be submitted for publication in peer-reviewed journals.Trial registration numberNCT04341350

Background Spontaneous breathing trial (SBT) using a T-piece remains the most frequently performed trial before extubation in ICUs. Research Question We aimed at determining whether initial SBT using pressure-support ventilation (PSV) could increase successful extubation rates among patients at high risk of extubation failure. Study Design and Methods Post hoc analysis of a multicenter trial focusing on reintubation in patients at high-risk of extubation failure. The initial SBT was performed using PSV or T-piece according to the physician/center decision. The primary outcome was the proportion of patients successfully extubated 72 hours after initial SBT, that is, extubated after initial SBT and not reintubated within the following 72 hours. Results Among the 641 patients included in the original study, initial SBT was performed using PSV (7.0 cm H2O in median without positive end-expiratory pressure) in 243 patients (38%) and using a T-piece in 398 patients (62%). The proportion of patients successfully extubated 72 hours after initial SBT was 67% (162/243) using PSV and 56% (223/398) using T-piece (absolute difference 10.6%; 95% CI, 2.8 to 28.1; P = .0076). The proportion of patients extubated after initial SBT was 77% (186/283) using PSV and 63% (249/398) using T-piece (P = .0002), whereas reintubation rates within the following 72 hours did not significantly differ (13% vs 10%, respectively; P = .4259). Performing an initial SBT using PSV was independently associated with successful extubation (adjusted OR, 1.60; 95% CI, 1.30 to 2.18; P = .0061). Interpretation In patients at high risk of extubation failure in the ICU, performing an initial SBT using PSV may hasten extubation without an increased risk of reintubation.

La Presse Medicale - In Press.Proof corrected by the author Available online since jeudi 11 juillet 2019

International audience; BACKGROUND: Non-invasive ventilation has never been compared with high-flow oxygen to determine whether it reduces the risk of severe hypoxaemia during intubation. We aimed to determine if preoxygenation with non-invasive ventilation was more efficient than high-flow oxygen in reducing the risk of severe hypoxaemia during intubation. METHODS: The FLORALI-2 multicentre, open-label trial was done in 28 intensive care units in France. Adult patients undergoing tracheal intubation for acute hypoxaemic respiratory failure (a partial pressure of arterial oxygen [PaO2] to fraction of inspired oxygen [FiO2] ratio of \textless/=300 mm Hg) were randomly assigned (1:1; block size, four participants) to non-invasive ventilation or high-flow oxygen during preoxygenation, with stratification by PaO2/FiO2 ratio (\textless/=200 mm Hg vs \textgreater200 mm Hg). Key exclusion criteria were intubation for cardiac arrest, altered consciousness (defined as a Glasgow coma score of less than eight points), other contraindications to non-invasive ventilation (recent laryngeal, oesophageal, or gastric surgery, and substantial facial fractures), pulse oximetry not available, pregnant or breastfeeding women, and refusal to participate. The primary outcome was the occurrence of severe hypoxaemia (pulse oximetry \textless80%) during the procedure, assessed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT02668458. FINDINGS: Between April 15, 2016, and Jan 8, 2017, 2079 patients were intubated in the 28 participating units, and 322 were enrolled. We excluded five patients with no recorded data, two who withdrew consent or were under legal protection, one who was not intubated, and one who had a cardiac arrest. Of the 313 patients included in the intention-to-treat analysis, 142 were assigned to non-invasive ventilation and 171 to high-flow oxygen therapy. Severe hypoxaemia occurred in 33 (23%) of 142 patients after preoxygenation with non-invasive ventilation and 47 (27%) of 171 with high-flow oxygen (absolute difference -4.2%, 95% CI -13.7 to 5.5; p=0.39). In the 242 patients with moderate-to-severe hypoxaemia (PaO2/FiO2 \textless/=200 mm Hg), severe hypoxaemia occurred less frequently after preoxygenation with non-invasive ventilation than with high-flow oxygen (28 [24%] of 117 patients vs 44 [35%] of 125; adjusted odds ratio 0.56, 0.32 to 0.99, p=0.0459). Serious adverse events did not differ between treatment groups, with the most common immediate complications being systolic arterial hypotension (70 [49%] patients in the non-invasive ventilation group vs 86 [50%] patients in the high-flow oxygen group) and chest infiltrate on x-ray (28 [20%] vs 33 [19%]), and the most common late complications being death at day 28 (53 [37%] vs 58 [34%]) and ventilator-associated pneumonia during ICU stay (31 [22%] vs 35 [20%]). INTERPRETATION: In patients with acute hypoxaemic respiratory failure, preoxygenation with non-invasive ventilation or high-flow oxygen therapy did not change the risk of severe hypoxaemia. Future research should explore the effect of preoxygenation method in patients with moderate-to-severe hypoxaemia at baseline. FUNDING: French Ministry of Health.

Spontaneous breathing trial (SBT) using a T-piece remains the most frequently performed trial before extubation in ICUs.We aimed at determining whether initial SBT using pressure-support ventilation (PSV) could increase successful extubation rates among patients at high risk of extubation failure.Post hoc analysis of a multicenter trial focusing on reintubation in patients at high-risk of extubation failure. The initial SBT was performed using PSV or T-piece according to the physician/center decision. The primary outcome was the proportion of patients successfully extubated 72 hours after initial SBT, that is, extubated after initial SBT and not reintubated within the following 72 hours.Among the 641 patients included in the original study, initial SBT was performed using PSV (7.0 cm HIn patients at high risk of extubation failure in the ICU, performing an initial SBT using PSV may hasten extubation without an increased risk of reintubation.

Key Points Question Are early brain changes seen on magnetic resonance imaging (MRI) associated with functional outcomes among adult patients with severe herpes simplex encephalitis (HSE)? Findings In adult patients with HSE, extensive brain changes seen on MRI during the first month after intensive care unit admission were independently associated with poor functional outcome at 90 days. Thalamic diffusion signal changes were frequently observed and were associated with poor prognosis, mainly in older patients. Meanings These findings suggest that, among adult patients with severe HSE, early MRI data were associated with neurological outcomes, both in terms of brain lesion extension and critical focal MRI signal changes., This cohort study investigates the association between early collected magnetic resonance imaging (MRI) data and functional outcomes 90 days after intensive care unit admission among adults with severe herpes simplex encephalitis., Importance Current guidelines recommend brain magnetic resonance imaging (MRI) for clinical management of patients with severe herpes simplex encephalitis (HSE). However, the prognostic value of brain imaging has not been demonstrated in this setting. Objective To investigate the association between early brain MRI data and functional outcomes of patients with HSE at 90 days after intensive care unit (ICU) admission. Design, Setting, and Participants This multicenter cohort study was conducted in 34 ICUs in France from 2007 to 2019 and recruited all patients who received a clinical diagnosis of encephalitis and exhibited cerebrospinal fluid positivity for herpes simplex virus DNA in the polymerase chain reaction analysis. Data analysis was performed from January to April 2020. Exposures All patients underwent a standard brain MRI during the first 30 days after ICU admission. Main Outcomes and Measures MRI acquisitions were analyzed by radiologists blinded to patients’ outcomes, using a predefined score. Multivariable logistic regression and supervised hierarchical classifiers methods were used to identify factors associated with poor outcome at 90 days, defined by a score of 3 to 6 (indicating moderate-to-severe disability or death) on the Modified Rankin Scale. Results Overall, 138 patients (median [interquartile range {IQR}] age, 62.6 [54.0-72.0] years; 75 men [54.3%]) with an admission median (IQR) Glasgow Coma Scale score of 9 (6-12) were studied. The median (IQR) delay between ICU admission and MRI was 1 (1-7) days. At 90 days, 95 patients (68.8%) had a poor outcome, including 16 deaths (11.6%). The presence of fluid-attenuated inversion recovery MRI signal abnormalities in more than 3 brain lobes (odds ratio [OR], 25.71; 95% CI, 1.21-554.42), age older than 60 years (OR, 7.62; 95% CI, 2.02-28.91), and the presence of diffusion-weighted MRI signal abnormalities in the left thalamus (OR, 6.90; 95% CI, 1.12-43.00) were independently associated with poor outcome. Machine learning models identified bilateral diffusion abnormalities as an additional factor associated with poor outcome (34 of 39 patients [87.2%] with bilateral abnormalities had poor outcomes) and confirmed the functional burden of left thalamic lesions, particularly in older patients (all 11 patients aged >60 years had left thalamic lesions). Conclusions and Relevance These findings suggest that in adult patients with HSE requiring ICU admission, extensive MRI changes in the brain are independently associated with poor functional outcome at 90 days. Thalamic diffusion signal changes were frequently observed and were associated with poor prognosis, mainly in older patients.

La Presse Medicale - In Press.Proof corrected by the author Available online since vendredi 26 fevrier 2016

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Objectives Since 1996, 1 to 4 annual training missions have been carried out to train Haitian otorhinolaryngology (ENT) and cervicofacial surgery residents by the association Liens Otorhinolaryngology Ayti (LOA). Until 1996, ENT was practiced and taught by ophthalmologists. The aim of this article is to describe the contributions and limitations of LOA in training of Haitian resident physicians and the creation of the ENT specialty in Haiti. Design Retrospective analysis of clinical consultation and surgical interventions records and didactics carried out during missions from 1996 through 2014. Participants A total of 37 missions were made during the 19-year period in which 29 senior ENT specialists participated, with an average of 3.37 missions per physician. Results A total of 10,300 consultations and 173 surgical procedures were made jointly by a senior LOA physician and a Haitian resident physician. Totally 16 Haitian ENT residents were trained, 81% of whom are still practicing in Haiti. ENT became a surgical specialty in 2001 after the nomination of a Haitian ENT specialist as Assistant Director of the ENT-Ophthalmology service. The latter benefitted from dual training by LOA in Haiti and abroad. Conclusion The Haitian population experiences significant difficulties with access to medical care owing to very low number of resident medical personnel. LOA’s work has contributed over 19 years to the training of ENT physicians now practicing in Haiti and to the creation of a local ENT specialty.

Importance High-flow nasal oxygen may prevent postextubation respiratory failure in the intensive care unit (ICU). The combination of high-flow nasal oxygen with noninvasive ventilation (NIV) may be an optimal strategy of ventilation to avoid reintubation. Objective To determine whether high-flow nasal oxygen with prophylactic NIV applied immediately after extubation could reduce the rate of reintubation, compared with high-flow nasal oxygen alone, in patients at high risk of extubation failure in the ICU. Design, Setting, and Participants Multicenter randomized clinical trial conducted from April 2017 to January 2018 among 641 patients at high risk of extubation failure (ie, older than 65 years or with an underlying cardiac or respiratory disease) at 30 ICUs in France; follow-up was until April 2018. Interventions Patients were randomly assigned to high-flow nasal oxygen alone (n = 306) or high-flow nasal oxygen with NIV (n = 342) immediately after extubation. Main Outcomes and Measures The primary outcome was the proportion of patients reintubated at day 7; secondary outcomes included postextubation respiratory failure at day 7, reintubation rates up until ICU discharge, and ICU mortality. Results Among 648 patients who were randomized (mean [SD] age, 70 [10] years; 219 women [34%]), 641 patients completed the trial. The reintubation rate at day 7 was 11.8% (95% CI, 8.4%-15.2%) (40/339) with high-flow nasal oxygen and NIV and 18.2% (95% CI, 13.9%-22.6%) (55/302) with high-flow nasal oxygen alone (difference, −6.4% [95% CI, −12.0% to −0.9%];P = .02). Among the 11 prespecified secondary outcomes, 6 showed no significant difference. The proportion of patients with postextubation respiratory failure at day 7 (21% vs 29%; difference, −8.7% [95% CI, −15.2% to −1.8%];P = .01) and reintubation rates up until ICU discharge (12% vs 20%, difference −7.4% [95% CI, −13.2% to −1.8%];P = .009) were significantly lower with high-flow nasal oxygen and NIV than with high-flow nasal oxygen alone. ICU mortality rates were not significantly different: 6% with high-flow nasal oxygen and NIV and 9% with high-flow nasal oxygen alone (difference, −2.4% [95% CI, −6.7% to 1.7%];P = .25). Conclusions and Relevance In mechanically ventilated patients at high risk of extubation failure, the use of high-flow nasal oxygen with NIV immediately after extubation significantly decreased the risk of reintubation compared with high-flow nasal oxygen alone. Trial Registration ClinicalTrials.gov Identifier:NCT03121482

La Presse Medicale - In Press.Proof corrected by the author Available online since mardi 3 mars 2015

Introduction The present study sought to identify factors affecting mortality beyond 28 days in ischaemic stroke patients with whatever ischaemic mechanism. Patients and methods A prospective population-based registry was set up in Brest County, Brittany, France. Demographic data, clinical presentation, vascular risk factors and mortality were collected from January 2008 to December 2012. At “home without help” was used as a surrogate marker for low Rankin (0–1) at discharge from the hospital. IS was classified on the TOAST classification. Overall mortality was calculated using the Kaplan–Meier method. Multivariate analysis of mortality beyond 28 days was implemented, using a Cox model, on significant risk factors identified on univariate analysis. Results About 3024 IS cases were followed up beyond 28 days. Overall mortality beyond 28 days was 38.49% at 60 months. On multivariate analysis, age (10 years: HR = 1.84; [1.66–2.02]), coronary artery disease (HR = 1.28; [1.05–1.56]), cardiac arrhythmia (HR = 1.36; [1.11–1.67]), peripheral artery disease (HR = 1.66 [1.29–2.13]) and incomplete assessment (HR = 1.39; [1.12–1.74]) were associated with higher mortality risk, whereas female gender (HR = 0.80; [0.68–0.94]), high Glasgow Coma Scale score (GCS > 12) (HR = 0.58; [0.45–0.76]), lacunar syndrome (HR = 0.82; [0.68–0.99], being ‘at home without help’ (HR = 0.50; [0.41–0.59]) and negative assessment (HR = 0.75; [0.58–0.97], compared to cardioembolism) were associated with better survival probability. Discussion Initial clinical status, prior cardiovascular diseases and age was associated with more risk of death: an increment of 10 years almost doubled mortality. Women had more survival probability than men, controlling for age. Ischaemic stroke mechanisms were predictors of late 5-year mortality. Conclusion Patients with negative assessment, i.e. representing truly cryptogenic ischaemic stroke, had the best survival probability probably due to fewer atherosclerotic markers.

40,000 psychiatric patients starved to death in France during the Nazi Occupation. Were they deliberately starved by the Vichy government because they were considered "useless mouths"? Did they die because hospital directors paid no attention to the equitable distribution of what were already substandard rations? To whom or to what can these deaths be attributed? Although the Vichy government enacted no deliberate plan to eliminate the mentally ill, lack of interest in the country's weakest members during a time of crisis led to tragic consequences.

ipe.2012.0892 Auteur(s) : Par les Dr H. Duchene et P. Bailly-Salin Meme si les signatures de cet article ont deja donne au lecteur un prejuge sur l’orientation de ses conclusions, nous aimerions qu’il poursuive quelle que soit sa position personnelle sur ce theme tres actuel de discussion. Contrairement a ce que l’on pourrait croire, nous sommes, en effet, « contre» le secteur tel que certains le concoivent et l’exercent actuellement et nous pensons qu’il existe trop de graves dangers [...]

The change of centuries, and especially the start of a new millennium, naturally encourages us to make assessments, to appraise the movement of ideas and the concrete achievements of the period that is ending, and to take a preliminary view of the evolutions that have marked its course. For example, in the area of assistance to mental patients, there is an extraordinary contrast between the approach taken in the first and the second half of the past century. Indeed, the contrast between the two periods is so remarkable that it provides us with an introduction.

A 32-year-old pregnant (20 weeks of amenorrhea) woman, after change in dietary intake (due to a trip to Korea), developed over 3 weeks progressive neuropsychological disorders associated with behavior disorders. The patient rapidly worsened, and had impaired consciousness and a coma. Biological tests showed hyperammonemia (173 µmol/L), glutamine chromatographic peak, and increased urinary orotic acid concentration. Brain MRI (figure 1) and spectroscopy (figure 2) findings were consistent with urea cycle disorders.1,2 A novel heterozygous mutation p.Ala209Glu (c.626C>A) in OTC gene was identified. She was treated with sodium benzoate, sodium phenylacetate, citrulline, hemofiltration, and reduced protein intake. Consciousness improved, and pregnancy was carried to completion, but mild cognitive impairment persisted 3 months later. The baby girl also carried the mutation but had no sequelae at 11 months.

To describe the presentation and clinical course of septic shock due to Toxoplasma gondii in patients infected with the human immunodeficiency virus (HIV).From April 1988 to February 1992, nine HIV-infected patients were admitted because of predominant septic shock (7 patients) or developed septic shock in the ICU (2 patients). The recent CD4+ cell count ranged from 2 to 84 x 10(6)/L.The main clinical features were (1) a history of fever for longer than 15 days, with a recent increase to more than 39.5 degrees C; (2) a recent history of dyspnea (15 days, 8 cases;7 days, 3 cases); and (3) recent onset of thrombocytopenia (6 of 9 cases). All patients were in shock (hyperkinetic profile in 6 of 7; hypokinetic in 1 of 7), and 8 of 9 were in respiratory distress (ratio of PaO2 over fractional concentration of oxygen in the inspired gas of 117 +/- 23; range, 88 to 155). Chest roentgenograms revealed diffuse alveolar infiltrates in six of nine cases. The serum lactate dehydrogenase (LDH) activity was 6,510 +/- 5,080 IU/L (range, 1,010 to 15,450 IU/L). Serologic tests for T gondii were negative in two cases. Toxoplasma gondii was isolated from lung (9/9), bone marrow (5/7), or blood (2/2). One, 3, and 2 patients had brain, ocular, and myocardial involvement, respectively. No other microbial pathogens were isolated. Seven patients died, 5 less than 3 days after admission.Disseminated toxoplasmosis can cause septic shock in HIV-infected patients. In two cases, the disease was probably a primary infection. The association of high fever, acute dyspnea, recent onset of thrombocytopenia, and a very high level of LDH activity is suggestive of disseminated toxoplasmosis.

10 p.; La mobilité des étudiants, et surtout, la mobilité internationale demande aux universités de solutionner une multitude de problèmes de "tuyauterie" dans les deux sens (sortant et entrant) : - mise à disposition de l'information pertinente sur les universités et les conditions d'études et de vie locales ; - enregistrement, filtrage et régulation des candidatures sortantes (et, éventuellement, entrantes) ; - formalités administratives ; - préparation linguistique (et culturelle au sens large) des étudiants sortant et, dans l'autre sens, accueil des étudiants entrant. Ces problèmes sont compliqués mais les responsables et les personnels administratifs parviennent à en venir à bout. Il apparaît alors que la dimension pédagogique de la question ne se réduit pas à l'indispensable apprentissage linguistique.

12 p.; L'Espace européen d'enseignement supérieur (EEES) constitue une rupture des schémas anciens en évaluant la qualité des diplômes par leur capacité à permettre des accès à des emplois. Deux enjeux principaux jouent un rôle majeur : d'une part constituer un espace européen de la formation débouchant sur un marché européen de l'emploi, d'autre part développer l'employabilité des jeunes formés dans les nouvelles technologies, condition de l'innovation et du développement de l'Europe dans une démarche qui est au fondement de la stratégie de Lisbonne. Le processus ne vise pas à aboutir à un ensemble homogène d'établissements indifférenciés mais à faciliter des échanges entre formations de même niveau. Cette démarche débouche sur la constitution d'un nouveau modèle des enseignements supérieurs fondé sur la confiance entre les partenaires.

Eine Reihe von Apothekengefässe mit Bildnisse von drei Schutzheiligen der Pharmazie. Die Verfasser geben Kund von zwölf Apothekengefässe welche verschiedenen hauptsächlich privaten Sammlungen angehören, und beschreiben ihre gemeinsame ähnliche Verzierung, welche in der Hauptsache aus Darstellungen der heiligen Kosmas und Damian und der Magdalena bestehen. Sie sind der Ansicht das diese Stücke (drei niedere Albarelli, fünf hohe Albarelli, drei Apothekentöpfe und eine Kanne) aus einer gleichen italienischen Werkstatt des 18. Jahrhunderts herrühren (Castelli ?)., A series of pharmacy jars with images of three saints patrons of pharmacy. The authors present and describe twelve pharmacy jars belonging to different-mostly private-collections, having in common the same decoration essentially in the form of the representation of Saints Cosmas and Damian and Magdalen. They think that these pieces (three small albarelli, five large albarelli, three pill jars and one spouted jar) originate from the same 18th century Italian atelier (Castelli ?), Bailly Pierre, Julien Pierre. Une série de vases pharmaceutiques aux effigies de trois patrons de la pharmacie. In: Revue d'histoire de la pharmacie, 81ᵉ année, n°297, 1993. pp. 217-224.

C’est a l’un des rares temoins de l’epoque qu’a ete demande un article consacre au soin et a l’activite. Soin au singulier et pas au pluriel, ce qui fait toute la difference. Et activite ? Au singulier ou au pluriel ? A savoir… Pourquoi ce renvoi a l’histoire ? Une histoire qui n’est pas seulement la mienne, mais l’histoire des Centres d’entrainement aux methodes d’education active aux tout debuts de leur aventure psychiatrique.

Background Our aim was to evaluate the impact of a computerized echocardiographic simulator on the learning curve for transesophageal echocardiography (TEE) hemodynamic assessment of ventilated patients in the ICU. Methods We performed a prospective study in two university hospital medical ICUs. Using our previously validated skill assessment scoring system (/40 points), we compared learning curves obtained with (interventional group, n = 25 trainees) and without (control group, n = 31 trainees) use of a simulator in the training. Three evaluations were performed after 1 (M1), 3 (M3) and 6 months (M6) while performing two TEE examinations graded by an expert. Competency was defined as a score >35/40. Results Competency was achieved after an average of 32.5 ± 10 supervised studies in the control group compared with only 13.6 ± 8.5 in the interventional group (p

International audience; Background: Spontaneous-breathing trials can be performed with the use of either pressure-support ventilation (PSV) or a T-piece. Whether PSV trials may result in a shorter time to tracheal extubation than T-piece trials, without resulting in a higher risk of reintubation, among patients who have a high risk of extubation failure is unknown.Methods: In this multicenter, open-label trial, we randomly assigned patients who had a high risk of extubation failure (i.e., were >65 years of age or had an underlying chronic cardiac or respiratory disease) to undergo spontaneous-breathing trials performed with the use of either PSV (with a pressure-support level of 8 cm of water and no positive end-expiratory pressure) or a T-piece. The primary outcome was the total time without exposure to invasive ventilation (reported as the number of ventilator-free days) at day 28 after the initial spontaneous-breathing trial. Secondary outcomes included extubation within 24 hours and extubation within 7 days after the initial spontaneous-breathing trial, as well as reintubation within 7 days after extubation.Results: A total of 969 patients (484 in the PSV group and 485 in the T-piece group) were included in the analysis. At day 28, the median number of ventilator-free days was 27 (interquartile range, 24 to 27) in the PSV group and 27 (interquartile range, 23 to 27) in the T-piece group (difference, 0 days; 95% confidence interval [CI], -0.5 to 1; P = 0.31). Extubation was performed within 24 hours in 376 patients (77.7%) in the PSV group and in 350 patients (72.2%) in the T-piece group (difference, 5.5 percentage points; 95% CI, 0.01 to 10.9), and extubation was performed within 7 days in 473 patients (97.7%) and 458 patients (94.4%), respectively (difference, 3.3 percentage points; 95% CI, 0.8 to 5.9). Reintubation was performed in 72 of 481 patients (14.9%) in the PSV group and in 65 of 477 patients (13.6%) in the T-piece group (difference, 1.3 percentage points; 95% CI, -3.1 to 5.8). Cardiac or respiratory arrest was a reason for reintubation in 9 patients (3 in the PSV group and 6 in the T-piece group).Conclusions: Among patients who had a high risk of extubation failure, spontaneous-breathing trials performed with PSV did not result in significantly more ventilator-free days at day 28 than spontaneous-breathing trials performed with a T-piece. (Supported by the French Ministry of Health; TIP-EX ClinicalTrials.gov number, NCT04227639.).