Utilization of mechanical power and associations with clinical outcomes in brain injured patients: a secondary analysis of the extubation strategies in neuro-intensive care unit patients and associations with outcome (ENIO) trial

Background: There is insufficient evidence to guide ventilatory targets in acute brain injury (ABI). Recent studies have shown associations between mechanical power (MP) and mortality in critical care populations. We aimed to describe MP in ventilated patients with ABI, and evaluate associations between MP and clinical outcomes. Methods: In this preplanned, secondary analysis of a prospective, multi-center, observational cohort study (ENIO, NCT03400904), we included adult patients with ABI (Glasgow Coma Scale ≤ 12 before intubation) who required mechanical ventilation (MV) ≥ 24 h. Using multivariable log binomial regressions, we separately assessed associations between MP on hospital day (HD)1, HD3, HD7 and clinical outcomes: hospital mortality, need for reintubation, tracheostomy placement, and development of acute respiratory distress syndrome (ARDS). Results: We included 1217 patients (mean age 51.2 years [SD 18.1], 66% male, mean body mass index [BMI] 26.3 [SD 5.18]) hospitalized at 62 intensive care units in 18 countries. Hospital mortality was 11% (n = 139), 44% (n = 536) were extubated by HD7 of which 20% (107/536) required reintubation, 28% (n = 340) underwent tracheostomy placement, and 9% (n = 114) developed ARDS. The median MP on HD1, HD3, and HD7 was 11.9 J/min [IQR 9.2-15.1], 13 J/min [IQR 10-17], and 14 J/min [IQR 11-20], respectively. MP was overall higher in patients with ARDS, especially those with higher ARDS severity. After controlling for same-day pressure of arterial oxygen/fraction of inspired oxygen (P/F ratio), BMI, and neurological severity, MP at HD1, HD3, and HD7 was independently associated with hospital mortality, reintubation and tracheostomy placement. The adjusted relative risk (aRR) was greater at higher MP, and strongest for: mortality on HD1 (compared to the HD1 median MP 11.9 J/min, aRR at 17 J/min was 1.22, 95% CI 1.14-1.30) and HD3 (1.38, 95% CI 1.23-1.53), reintubation on HD1 (1.64; 95% CI 1.57-1.72), and tracheostomy on HD7 (1.53; 95%CI 1.18-1.99). MP was associated with the development of moderate-severe ARDS on HD1 (2.07; 95% CI 1.56-2.78) and HD3 (1.76; 95% CI 1.41-2.22). Conclusions: Exposure to high MP during the first week of MV is associated with poor clinical outcomes in ABI, independent of P/F ratio and neurological severity. Potential benefits of optimizing ventilator settings to limit MP warrant further investigation

The blockchain folk theorem

International audienceBlockchains are distributed ledgers, operated within peer-to-peer networks. We model the proof-of-work blockchain protocol as a stochastic game and analyze the equilibrium strategies of rational, strategic miners. Mining the longest chain is a Markov perfect equilibrium, without forking, in line with Nakamoto (2008). The blockchain protocol, however, is a coordination game, with multiple equilibria. There exist equilibria with forks, leading to orphaned blocks and persistent divergence between chains. We also show how forks can be generated by information delays and software upgrades. Last we identify negative externalities implying that equilibrium investment in computing capacity is excessiv

The blockchain folk theorem

International audienceBlockchains are distributed ledgers, operated within peer-to-peer networks. We model the proof-of-work blockchain protocol as a stochastic game and analyze the equilibrium strategies of rational, strategic miners. Mining the longest chain is a Markov perfect equilibrium, without forking, in line with Nakamoto (2008). The blockchain protocol, however, is a coordination game, with multiple equilibria. There exist equilibria with forks, leading to orphaned blocks and persistent divergence between chains. We also show how forks can be generated by information delays and software upgrades. Last we identify negative externalities implying that equilibrium investment in computing capacity is excessiv

Evaluation of proposed harvest control rules for Bay of Biscay sole

The evaluations reported here were carried out following an EU request to ICES on an evaluation of proposed harvest control rules for sole in the Bay of Biscay. The authors worked together in September 2013 to answer this request. Their affiliations are listed in the Annex

Chest trauma: First 48 hours management

International audienceChest trauma remains an issue for health services for both severe and apparently mild trauma management. Severe chest trauma is associated with high mortality and is considered liable for 25% of mortality in multiple traumas. Moreover, mild trauma is also associated with significant morbidity especially in patients with preexisting conditions. Thus, whatever the severity, a fast-acting strategy must be organized. At this time, there are no guidelines available from scientific societies. These expert recommendations aim to establish guidelines for chest trauma management in both prehospital an in hospital settings, for the first 48 hours. The ``Societe francaise d'anesthesie reanimation'' and the ``Societe francaise de mdecine d'urgence'' worked together on the 7 following questions: (1) criteria defining severity and for appropriate hospital referral; (2) diagnosis strategy in both pre- and in-hospital settings; (3) indications and guidelines for ventilatory support; (4) management of analgesia; (5) indications and guidelines for chest tube placement; (6) surgical and endovascular repair indications in blunt chest trauma; (7) definition, medical and surgical specificity of penetrating chest trauma. For each question, prespecified ``crucial'' (and sometimes also ``important'') outcomes were identified by the panel of experts because it mattered for patients. We rated evidence across studies for these specific clinical outcomes. After a systematic Grade (R) approach, we defined 60 recommendations. Each recommendation has been evaluated by all the experts according to the DELPHI method. (C) 2017 Societe francaise d'anesthesie et de reanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved

Les ressources exploitées par la pêche et la conchyliculture

L'exploitation des ressources par la pêche professionnelle et par la conchyliculture repose sur des ressources vivantes sauvages ou domestiquées qui sont présentes dans différents milieux aquatiques depuis les rivières jusqu'au large en mer. L'état de ces populations dépend non seulement des choix d'exploitation au regard des capacités de renouvellement des stocks mais aussi des caractéristiques environnementales qui impactent les différentes phases des cycles biologiques des espèces et jouent donc sur leur bon déroulement. Ces conditions du milieu sont tributaires pour partie des activités anthropiques (qualité et quantité d'eau disponible, obstacles au franchissement, autres perturbations) et peuvent être soumises aux effets du changement climatique. Ce chapitre s'intéresse à quinze espèces d'importance pour la pêche et la conchyliculture en Nouvelle-Aquitaine : l'algue rouge, l'anchois commun, l'anguille européenne, le bar commun, les baudroies d'Europe, la dorade royale, la grande alose, le maigre, le maquereau commun, le merlu européen, la palourde japonaise, le saumon atlantique, la sole commune, l'huître creuse japonaise et la moule bleue. Après une présentation des activités et des habitats essentiels pour les populations naturelles, une synthèse des changements de l'environnement et des impacts sur ces espèces déjà observés et attendus est présentée. Il s'ensuit un état des lieux des impacts déjà constatés sur les pêcheries et sur les entreprises conchylicoles. Le chapitre s'achève par une discussion sur les adaptations pour les entreprises et des enjeux associés. Ce chapitre fait partie de l'ouvrage réalisé par le Comité Scientifique Régional AcclimaTerra ; ouvrage qui comporte au total 15 chapitres. Ce travail sur le changement climatique en Nouvelle-Aquitaine est à l'initiative de la Région Nouvelle-Aquitaine

ICES. 2011. Report of the Joint ICES-STECF Workshop on management plan evalua-tions for roundfish stocks (WKROUNDMP/EWG 11-01), 28 February - 4 March 2011

A joint ICES / STECF meeting met 28 February to 4 March in Copenhagen, for prepa-ration of Impact Assessments for Bay of Biscay sole and Baltic Cod, and historic Evaluations of existing plans for Kattegat, North Sea, West of Scotland and Irish Sea cod. The meeting involves STECF, ICES scientists dealing with Economy and Biology and Observers (Commission staff, Managers, Stakeholders). The workshop has fully addressed its Terms of Reference, and progress has been made in all areas. The Impact Assessment of Bay of Biscay was fully completed, the biological aspects were relatively straightforward, with a clearly defined single species MSY target for exploitation of this stock. It is anticipated that exploitation at MSY will give biomass that is significantly above any precautionary reference points and thus maximising exploitation forms the main criteria. The economic evaluations were if a very high standard, probably the best done so far under STECF. The work required for the impact assessment of Baltic cod was identified and is documented in the report. In most cases the work is clear, although some minor de-tails in parameterisation remain to be finalised. There was considerable discussion of single species / multi-species targets for Baltic cod. The issues raised are multi-species in the context of population interactions affecting yields, not multi-species in a mixed fisheries context of reconciling different catch rate targets in a mixed fishery. For Bal-tic cod plans this aspect has not been resolved, as currently no work detailing as-sumptions and results has been presented within the group. Currently STECF and ICES develop MSY targets based in single species evaluations. It is clear that multi-species aspects can be parameterised more easily in the Baltic (and Barents Sea) than in other areas where the species complexity is greater. Cur-rently it is unclear how STECF or ICES should base advice. While we hope to resolve some of these issues others may not be resolvable within the scope of this study. For the group to understand the issues and give sound advice it is important that those responsible for the analyses provide a good description of their assumptions and the sensitivity of the results to model assumptions and choice of parameters. In this context the basis of studies and the results need to be circulated in advance of the meeting. A brief outline of the requirements to deliver the answers to questions on NS whiting is provided. The work will be carried out prior to WGNSSK in May and draft advice will be passed to ADGNS from WKNSSK. If WKNSSK is satisfied with the work it will be passed directly to ADGNS and subsequently ACOM. If substantive revision is required and further review needed this will be done at the next meeting of WKROU-ND2011 20-24 June 2011.JRC.DG.G.4-Maritime affair

Effect of the use of an endotracheal tube and stylet versus an endotracheal tube alone on first-attempt intubation success: a multicentre, randomised clinical trial in 999 patients

International audiencePurpose: The effect of the routine use of a stylet during tracheal intubation on first-attempt intubation success is unclear. We hypothesised that the first-attempt intubation success rate would be higher with tracheal tube + stylet than with tracheal tube alone.Methods: In this multicentre randomised controlled trial, conducted in 32 intensive care units, we randomly assigned patients to tracheal tube + stylet or tracheal tube alone (i.e. without stylet). The primary outcome was the proportion of patients with first-attempt intubation success. The secondary outcome was the proportion of patients with complications related to tracheal intubation. Serious adverse events, i.e., traumatic injuries related to tracheal intubation, were evaluated.Results: A total of 999 patients were included in the modified intention-to-treat analysis: 501 (50%) to tracheal tube + stylet and 498 (50%) to tracheal tube alone. First-attempt intubation success occurred in 392 patients (78.2%) in the tracheal tube + stylet group and in 356 (71.5%) in the tracheal tube alone group (absolute risk difference, 6.7; 95%CI 1.4-12.1; relative risk, 1.10; 95%CI 1.02-1.18; P = 0.01). A total of 194 patients (38.7%) in the tracheal tube + stylet group had complications related to tracheal intubation, as compared with 200 patients (40.2%) in the tracheal tube alone group (absolute risk difference, - 1.5; 95%CI - 7.5 to 4.6; relative risk, 0.96; 95%CI 0.83-1.12; P = 0.64). The incidence of serious adverse events was 4.0% and 3.6%, respectively (absolute risk difference, 0.4; 95%CI, - 2.0 to 2.8; relative risk, 1.10; 95%CI 0.59-2.06. P = 0.76).Conclusions: Among critically ill adults undergoing tracheal intubation, using a stylet improves first-attempt intubation success