Impact of whole-body computed tomography on mortality and surgical management of severe blunt trauma

International audienceIntroductionThe mortality benefit of whole-body computed tomography (CT) in early trauma management remains controversial and poorly understood. The objective of this study was to assess the impact of whole-body CT compared with selective CT on mortality and management of patients with severe blunt trauma.MethodsThe FIRST (French Intensive care Recorded in Severe Trauma) study is a multicenter cohort study on consecutive patients with severe blunt trauma requiring admission to intensive care units from university hospital trauma centers within the first 72 hours. Initial data were combined to construct a propensity score to receive whole-body CT and selective CT used in multivariable logistic regression models, and to calculate the probability of survival according to the Trauma and Injury Severity Score (TRISS) for 1,950 patients. The main endpoint was 30-day mortality.ResultsIn total, 1,696 patients out of 1,950 (87%) were given whole-body CT. The crude 30-day mortality rates were 16% among whole-body CT patients and 22% among selective CT patients (p = 0.02). A significant reduction in the mortality risk was observed among whole-body CT patients whatever the adjustment method (OR = 0.58, 95% CI: 0.34-0.99 after adjustment for baseline characteristics and post-CT treatment). Compared to the TRISS predicted survival, survival significantly improved for whole-body CT patients but not for selective CT patients. The pattern of early surgical and medical procedures significantly differed between the two groups.ConclusionsDiagnostic whole-body CT was associated with a significant reduction in 30-day mortality among patients with severe blunt trauma. Its use may be a global indicator of better management

A human postnatal lymphoid progenitor capable of circulating and seeding the thymus

Identification of a thymus-seeding progenitor originating from human bone marrow (BM) constitutes a key milestone in understanding the mechanisms of T cell development and provides new potential for correcting T cell deficiencies. We report the characterization of a novel lymphoid-restricted subset, which is part of the lineage-negative CD34+CD10+ progenitor population and which is distinct from B cell–committed precursors (in view of the absence of CD24 expression). We demonstrate that these Lin−CD34+CD10+CD24− progenitors have a very low myeloid potential but can generate B, T, and natural killer lymphocytes and coexpress recombination activating gene 1, terminal deoxynucleotide transferase, PAX5, interleukin 7 receptor α, and CD3ε. These progenitors are present in the cord blood and in the BM but can also be found in the blood throughout life. Moreover, they belong to the most immature thymocyte population. Collectively, these findings unravel the existence of a postnatal lymphoid-polarized population that is capable of migrating from the BM to the thymus

Mesure du fibrinogène fonctionnel en thromboélastographie (évaluation précoce de la coagulopathie traumatique)

Contexte : Le fibrinogène atteint précocement sa valeur limite dans la coagulopathie traumatique aigüe (CTA). Celle-ci aggrave la mortalité et les besoins transfusionnels, mais n a qu une définition clinique. L objectif principal de notre étude a été d évaluer la fiabilité de la mesure du Fibrinogène Fonctionnel (FLEV) en thromboélastographie (TEG ) comparativement à la technique de référence CLAUSS. Les objectifs secondaires ont été d objectiver le gain de temps de la mesure réalisée au déchocage ou au laboratoire (FLEVn et FLEVc) par rapport à la technique CLAUSS, de la confronter aux marqueurs de risque de CTA et d en proposer un seuil transfusionnel pour les concentrés de fibrinogène.Méthode : Une étude prospective observationnelle sur six mois a inclus les traumatisés bénéficiant d une mesure du fibrinogène Clauss et FLEVc et/ou FLEVn et un sous-groupe A (mesures à l admission avant réanimation hémostatique). Un test de Wilcoxon apparié, des représentations de Bland et Altman et une étude de concordance ont été utilisés pour comparer les méthodes. Les délais entre le prélèvement et le résultat des tests a été comparé (Wilcoxon apparié). Des arbres décisionnels (CHAID) ont déterminé un seuil de FLEV et des courbes ROC ont été établies en fonction des marqueurs de risque de CTA du sous-groupe A (ISS>25, score MGAP-6 mmol/l, ratio de temps de prothrombine patient/témoin (rTQ)>1,20). Les résultats ont été exprimés en médiane interquartile (p1,20 à l admission (sous-groupe A), un seuil de FLEVc à 1,9 g/l a eu une sensibilité et une spécificité comparable à celles des autres marqueurs de gravité et une valeur prédictive positive de 100%.Conclusion : Le FLEV permet de diagnostiquer rapidement les hypofibrinogénémies et pourrait être un marqueur de CTA. En dessous de 1,9 g/l, les traumatisés auraient un risque de 100% de présenter des troubles de la coagulation.LILLE2-BU Santé-Recherche (593502101) / SudocSudocFranceF

Impact de la technique anesthésique sur le stress péri opératoire de l'enfant (ALR versus AG pour les fractures du membre supérieur)

LILLE2-BU Santé-Recherche (593502101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Traumatismes graves du bassin et artériographie-embolisation des vaisseaux pelviens (étude clinique sur deux ans)

LILLE2-BU Santé-Recherche (593502101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

La prise en charge des traumatisés crâniens graves dans l'unité de réanimation des urgences de l'Hôpital Roger Salengro, au CHR de Lille (description de la population et analyse critique de la filière de soins)

LILLE2-BU Santé-Recherche (593502101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Association of Organizational Pathways With the Delay of Emergency Surgery.

International audienceImportance Delayed admission of patients with surgical emergencies to the operating room occurs frequently and is associated with poor outcomes. In France, where 3 distinct organizational pathways in hospitals exist (a dedicated emergency operating room and team [DET], a dedicated operating room in a central operating theater [DOR], and no dedicated structure or team [NOR]), neither the incidence nor the influence of delayed urgent surgery is known, and no guidelines are available to date.Objective To examine the overall frequency of delayed admission of patients with surgical emergencies to the operating room across the 3 organizational pathways in hospitals in France.Design, Setting, and Participants This prospective multicenter cohort study was conducted in 10 French tertiary hospitals. All consecutive adult patients admitted for emergency surgery from October 5 to 16, 2020, were included and prospectively monitored. Patients requiring pediatric surgery, obstetrics, interventional radiology, or endoscopic procedures were excluded.Exposures Emergency surgery.Main Outcomes and Measures The main outcome was the global incidence of delayed emergency surgery across 3 predefined organizational pathways: DET, DOR, and NOR. The ratio between the actual time to surgery (observed duration between surgical indication and incision) and the ideal time to surgery (predefined optimal duration between surgical indication and incision according to the Non-Elective Surgery Triage classification) was calculated for each patient. Surgery was considered delayed when this ratio was greater than 1.Results A total of 1149 patients were included (mean [SD] age, 55 [21] years; 685 [59.9%] males): 649 in the DET group, 320 in the DOR group, and 171 in the NOR group (missing data: n = 5). The global frequency of surgical delay was 32.5% (95% CI, 29.8%-35.3%) and varied across the 3 organizational pathways: DET, 28.4% (95% CI, 24.8%-31.9%); DOR, 32.2% (95% CI, 27.0%-37.4%); and NOR, 49.1% (95% CI, 41.6%-56.7%) (P < .001). The adjusted odds ratio for delay was 1.80 (95% CI, 1.17-2.78) when comparing NOR with DET.Conclusions and Relevance In this cohort study, the frequency of delayed emergency surgery in France was 32.5%. Reduced delays were found in organizational pathways that included dedicated theaters and teams. These preliminary results may pave the way for comprehensive large-scale studies, from which results may potentially inform new guidelines for quicker and safer access to emergency surgery

Design, synthesis, and biological evaluation of a multifunctional neuropeptide-Y conjugate for selective nuclear delivery of radiolanthanides

International audienceBackground Targeting G protein-coupled receptors on the surface of cancer cells with peptide ligands is a promising concept for the selective tumor delivery of therapeutically active cargos, including radiometals for targeted radionuclide therapy (TRT). Recently, the radiolanthanide terbium-161 (Tb-161) gained significant interest for TRT application, since it decays with medium-energy beta-radiation but also emits a significant amount of conversion and Auger electrons with short tissue penetration range. The therapeutic efficiency of radiometals emitting Auger electrons, like Tb-161, can therefore be highly boosted by an additional subcellular delivery into the nucleus, in order to facilitate maximum dose deposition to the DNA. In this study, we describe the design of a multifunctional, radiolabeled neuropeptide-Y (NPY) conjugate, to address radiolanthanides to the nucleus of cells naturally overexpressing the human Y-1 receptor (hY(1)R). By using solid-phase peptide synthesis, the hY(1)R-preferring [F-7,P-34]-NPY was modified with a fatty acid, a cathepsin B-cleavable linker, followed by a nuclear localization sequence (NLS), and a DOTA chelator (compound pb12). In this proof-of-concept study, labeling was performed with either native terbium-159 (Tb-nat), as surrogate for Tb-161, or with indium-111 (In-111). Results [Tb-nat]Tb-pb12 showed a preserved high binding affinity to endogenous hY(1)R on MCF-7 cells and was able to induce receptor activation and internalization similar to the hY(1)R-preferring [F-7,P-34]-NPY. Specific internalization of the In-111-labeled conjugate into MCF-7 cells was observed, and importantly, time-dependent nuclear uptake of In-111 was demonstrated. Study of metabolic stability showed that the peptide is insufficiently stable in human plasma. This was confirmed by injection of [In-111]In-pb12 in nude mice bearing MCF-7 xenograft which showed specific uptake only at very early time point. Conclusion The multifunctional NPY conjugate with a releasable DOTA-NLS unit represents a promising concept for enhanced TRT with Auger electron-emitting radiolanthanides. Our research is now focusing on improving the reported concept with respect to the poor plasmatic stability of this promising radiopeptide

Medical pre-hospital management reduces mortality in severe blunt trauma: a prospective epidemiological study.

International audienceINTRODUCTION: Severe blunt trauma is a leading cause of premature death and handicap. However, the benefit for the patient of pre-hospital management by emergency physicians remains controversial because it may delay admission to hospital. This study aimed to compare the impact of medical pre-hospital management performed by SMUR (Service Mobile d'Urgences et de Réanimation) with non-medical pre-hospital management provided by fire brigades (non-SMUR) on 30-day mortality. METHODS: The FIRST (French Intensive care Recorded in Severe Trauma) study is a multicenter cohort study on consecutive patients with severe blunt trauma requiring admission to university hospital intensive care units within the first 72 hours. Initial clinical status, pre-hospital life-sustaining treatments and Injury Severity Scores (ISS) were recorded. The main endpoint was 30-day mortality. RESULTS: Among 2,703 patients, 2,513 received medical pre-hospital management from SMUR, and 190 received basic pre-hospital management provided by fire brigades. SMUR patients presented a poorer initial clinical status and higher ISS and were admitted to hospital after a longer delay than non-SMUR patients. The crude 30-day mortality rate was comparable for SMUR and non-SMUR patients (17% and 15% respectively; P = 0.61). After adjustment for initial clinical status and ISS, SMUR care significantly reduced the risk of 30-day mortality (odds ratio (OR): 0.55, 95% CI: 0.32 to 0.94, P = 0.03). Further adjustments for the delay to hospital admission only marginally affected these results. CONCLUSIONS: This study suggests that SMUR management is associated with a significant reduction in 30-day mortality. The role of careful medical assessment and intensive pre-hospital life-sustaining treatments needs to be assessed in further studies