An integrated approach for prescribing fewer chest x-rays in the ICU

Chest x-rays (CXRs) are the main imaging tool in intensive care units (ICUs). CXRs also are associated with concerns inherent to their use, considering both healthcare organization and patient perspectives. In recent years, several studies have focussed on the feasibility of lowering the number of bedside CXRs performed in the ICU. Such a decrease may result from two independent and complementary processes: a raw reduction of CXRs due to the elimination of unnecessary investigations, and replacement of the CXR by an alternative technique. The goal of this review is to outline emblematic examples corresponding to these two processes. The first part of the review concerns the accumulation of evidence-based data for abandoning daily routine CXRs in mechanically ventilated patients and adopting an on-demand prescription strategy. The second part of the review addresses the use of alternative techniques to CXRs. This part begins with the presentation of ultrasonography or capnography combined with epigastric auscultation for ensuring the correct position of enteral feeding tubes. Ultrasonography is then also presented as an alternative to CXR for diagnosing and monitoring pneumothoraces, as well as a valuable post-procedural technique after central venous catheter insertion. The combination of the emblematic examples presented in this review supports an integrated global approach for decreasing the number of CXRs ordered in the ICU

A thyrotoxicosis outbreak due to dietary pills in Paris

Vincent Ioos1, Vincent Das1, Eric Maury1,2, Jean-Luc Baudel1, Jérôme Guéchot3, Bertrand Guidet1,2, Georges Offenstadt1,21Réanimation Médicale; 2Université Pierre et Marie Curie-Paris 6, INSERM, UMR-S 707; 3Unité d’Hormonologie, APHP, Hôpital Saint Antoine, F-75012, Paris, FranceAbstract: 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.Keywords: thyrotoxicosis, dietary pills, thyroxi

Patients in ICUs Indications of Chest Radiographs for A Web-Based Delphi Study on the Indications of Chest Radiographs for Patients in ICUs*

Detailed feedback for the answers given during the previous round was supplied to each intensivist solicited for updating his answers. Results: Eighty-two intensivists from 32 ICUs completed the study. A consensus emerged that routine CXRs were necessary for eight scenarios and unnecessary for two scenarios. The study also shed light on items without a consensus. In particular, 75% of intensivists (58% on the first round) did not support obtaining daily routine CXRs in intubated patients. Conclusion: The study underlines situations in which intensivists do not support the guidelines and outlines recommendations likely to be followed in clinical practice

Continuous Positive Airway Pressure (CPAP) face-mask ventilation is an easy and cheap option to manage a massive influx of patients presenting acute respiratory failure during the SARS-CoV-2 outbreak: A retrospective cohort study.

IntroductionBecause of the COVID-19 pandemic, intensive care units (ICU) can be overwhelmed by the number of hypoxemic patients.Material and methodsThis single centre retrospective observational cohort study took place in a French hospital where the number of patients exceeded the ICU capacity despite an increase from 18 to 32 beds. Because of this, 59 (37%) of the 159 patients requiring ICU care were referred to other hospitals. From 27th March to 23rd April, consecutive patients who had respiratory failure or were unable to maintain an SpO2 > 90%, despite receiving 10-15 l/min of oxygen with a non-rebreather mask, were treated by continuous positive airway pressure (CPAP) unless the ICU physician judged that immediate intubation was indicated. We describe the characteristics, clinical course, and outcomes of these patients. The main outcome under study was CPAP discontinuation.ResultsCPAP was initiated in 49 patients and performed out of ICU in 41 (84%). Median age was 65 years (IQR = 54-71) and 36 (73%) were men. Median respiratory rate before CPAP was 36 (30-40) and median SpO2 was 92% (90-95) under 10 to 15 L/min oxygen flow. Median duration of CPAP was 3 days (IQR = 1-5). Reasons for discontinuation of CPAP were: intubation in 25 (51%), improvement in 16 (33%), poor tolerance in 6 (12%) and death in 2 (4%) patients. A decision not to intubate had been taken for 8 patients, including the 2 who died while on CPAP. Two patients underwent less than one hour CPAP for poor tolerance. In the end, 15 (38%) out of 39 evaluable patients recovered with only CPAP whereas 24 (62%) were intubated.ConclusionsCPAP is feasible in a non-ICU environment in the context of massive influx of patients. In our cohort up to 1/3 of the patients presenting with acute respiratory failure recovered without intubation

Spectrum of pontocerebellar hypoplasia in 13 girls and boys with <it>CASK </it>mutations: confirmation of a recognizable phenotype and first description of a male mosaic patient

<p>Abstract</p> <p>Background</p> <p>Pontocerebellar hypoplasia (PCH) is a heterogeneous group of diseases characterized by lack of development and/or early neurodegeneration of cerebellum and brainstem. According to clinical features, seven subtypes of PCH have been described, PCH type 2 related to <it>TSEN54 </it>mutations being the most frequent. PCH is most often autosomal recessive though <it>de novo </it>anomalies in the X-linked gene <it>CASK </it>have recently been identified in patients, mostly females, presenting with intellectual disability, microcephaly and PCH (MICPCH).</p> <p>Methods</p> <p>Fourteen patients (12 females and two males; aged 16 months-14 years) presenting with PCH at neuroimaging and with clinical characteristics unsuggestive of PCH1 or PCH2 were included. The <it>CASK </it>gene screening was performed using Array-CGH and sequencing. Clinical and neuroradiological features were collected.</p> <p>Results</p> <p>We observed a high frequency of patients with a <it>CASK </it>mutation (13/14). Ten patients (8 girls and 2 boys) had intragenic mutations and three female patients had a Xp11.4 submicroscopic deletion including the <it>CASK </it>gene. All were <it>de novo </it>mutations. Phenotype was variable in severity but highly similar among the 11 girls and was characterized by psychomotor retardation, severe intellectual disability, progressive microcephaly, dystonia, mild dysmorphism, and scoliosis. Other signs were frequently associated, such as growth retardation, ophthalmologic anomalies (glaucoma, megalocornea and optic atrophy), deafness and epilepsy. As expected in an X-linked disease manifesting mainly in females, the boy hemizygous for a splice mutation had a very severe phenotype with nearly no development and refractory epilepsy. We described a mild phenotype in a boy with a mosaic truncating mutation. We found some degree of correlation between severity of the vermis hypoplasia and clinical phenotype.</p> <p>Conclusion</p> <p>This study describes a new series of PCH female patients with <it>CASK </it>inactivating mutations and confirms that these patients have a recognizable although variable phenotype consisting of a specific form of pontocerebellar hypoplasia. In addition, we report the second male patient to present with a severe MICPCH phenotype and a <it>de novo CASK </it>mutation and describe for the first time a mildly affected male patient harboring a mosaic mutation. In our reference centre, <it>CASK </it>related PCH is the second most frequent cause of PCH. The identification of a <it>de novo </it>mutation in these patients enables accurate and reassuring genetic counselling.</p

Movement disorders in patients with alternating hemiplegia: "Soft" and "stiff" at the same time

International audienceAIM: To assess non-paroxysmal movement disorders in ATP1A3 mutation-positive patients with alternating hemiplegia of childhood (AHC).METHODS: Twenty-eight patients underwent neurological examination with particular focus on movement phenomenology by a specialist in movement disorders. Video recordings were reviewed by another movement disorders specialist and data were correlated to patients’ characteristics.RESULTS: Ten patients were diagnosed with chorea, 16 with dystonia (nonparoxysmal), 4 with myoclonus, and 2 with ataxia. Nine patients had more than one movement disorder and 8 patients had none. The degree of movement disorder was moderate to severe in 12/28 patients. At inclusion, dystonic patients (n=16) were older (p=0.007) than nondystonic patients. Moreover, patients (n=18) with dystonia or chorea, or both, had earlier disease onset (p=0.042) and more severe neurological impairment (p=0.012), but this did not correlate with genotype. All patients presented with hypotonia, which was characterized as moderate or severe in 16/28. Patients with dystonia or chorea (n=18) had more pronounced hypotonia (p=0.011). Bradykinesia (n=16) was associated with an early age at assessment (p<0.01). Significant dysarthria was diagnosed in 11/25 cases. A history of acute neurological deterioration and further regression of motor function, typically after a stressful event, was reported in 7 patients.INTERPRETATION: Despite the relatively limited number of patients and the cross-sectional nature of the study, this detailed categorisation of movement disorders in patients with AHC offers valuable insight into their precise characterization. Further longitudinal studies on this topic are needed