Predictive Factors of Poor Prognosis After Surgical Management of Traumatic Acute Subdural Hematomas: A Single-Center Series

BACKGROUND: Traumatic acute subdural hematomas (ASDHs) showed the highest mortality of intracranial hematomas. The aim of the current study was to identify predictive factors of poor prognosis among patients who were operated on. METHODS: This is a single-center retrospective cohort study of 82 patients who underwent surgical evacuation of a traumatic ASDH between January 2009 and December 2016. The epidemiologic, clinical, radiologic, and surgical features were recorded. Postoperative outcome were assessed by the Glasgow Outcome Scale (GOS) score at 6 months. Univariate and multivariate analysis and a classification and regression tree (CART) were performed. RESULTS: At 6 months, 76% of patients achieved an unfavorable outcome (GOS score 1-3). The context of polytrauma (P = 0.03) and ASDH thickness ≥20 mm (P = 0.02) were significantly associated with poor outcome in the multivariate analysis. The CART algorithm isolated 3 subgroups of patients with an unfavorable prognosis: polytrauma (91%), isolated head injury (HI) featuring an ASDH thickness ≥20 mm (89%), or isolated HI featuring a thickness <20 mm in a patient older than 54 years (71%). Isolated patients with HI younger than 54 years harboring an ASDH <20 mm thick had the most promising results, with 53% with a GOS score of 4 or 5. CONCLUSIONS: The context of polytrauma, ASDH thickness, and age were major predictive factors of poor prognosis in patients with surgically evacuated traumatic ASDH. The CART algorithm using these features isolated subgroups with decreasingly unfavorable outcome, providing a relevant statistical tool to apply to future studies of traumatic ASDH

Hypoxia-inducible factor (HIF1α) gene expression in human shock states.

International audienceABSTRACT: INTRODUCTION: Hypoxia-inducible factor-1 (HIF1) controls the expression of genes involved in the cellular response to hypoxia. No information is available on its expression in critically ill patients. Thus, we designed the first clinical study in order to evaluate the role of HIF1α as a prognosis marker in patients suffering from shock. METHODS: Fifty consecutive adult patients with shock and 11 healthy volunteers were prospectively enrolled in the study. RNA was extracted from whole blood samples and expression of HIF1α was assessed over the first four hours of shock. The primary objective was to assess HIF1α as a prognostic marker in shock. Secondary objectives were to evaluate the role of HIF1α as a diagnostic and follow-up marker. Patient survival was evaluated at day 28. RESULTS: The causes of shock were sepsis (78%), hemorrhage (18%), and cardiac dysfunction (4%). HIF1α expression was significantly higher in the shock patients than in the healthy volunteers (121 (range: 72-168) versus 48 (range: 38-54) normalized copies, P <0.01), whatever the measured isoforms. It was similar in non-survivors and survivors (108 (range 84-183) versus 121(range 72-185) normalized copies, P = 0.92), and did not significantly change within the study period. CONCLUSIONS: The present study is the first to demonstrate an increased expression of HIF1α in patients with shock. Further studies are needed to clarify the potential association with outcome. Our findings reinforce the value of monitoring plasma lactate levels to guide the treatment of shock

Multi-organ point-of-care ultrasound for COVID-19 (PoCUS4COVID): international expert consensus.

COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research.post-print2.282 K

Diagnosis of hemidiaphragm paralysis: refine ultrasound criteria

BackgroundUltrasound has demonstrated its interest in the analysis of diaphragm function in patients with respiratory failure. The criteria used to diagnose hemidiaphragm paralysis are not well defined.MethodsThe aim of this observational retrospective study was to describe the ultrasound findings in 103 patients with diaphragm paralysis, previously diagnosed by conventional methods after various circumstances such as trauma or surgery. The ultrasound study included the recording of excursions of both diaphragmatic domes and the measurement of inspiratory thickening.ResultsOn paralyzed hemidiaphragm, thickening was less than 20% in all patients during deep inspiration. Thinning was recorded in 53% of cases. In some cases, the recording of the thickening could be difficult. The study of motion during voluntary sniffing reported a paradoxical excursion in all but one patient. During quiet breathing, an absence of movement or a paradoxical displacement was observed. During deep inspiration, a paradoxical motion at the beginning of inspiration followed by a reestablishment of movement in the cranio-caudal direction was seen in 82% of cases. In some patients, there was a lack of movement followed, after an average delay of 0.4 s, by a cranio-caudal excursion. Finally, in 4 patients no displacement was recorded. Evidence of hyperactivity (increased inspiratory thickening and excursion) of contralateral non-paralyzed hemidiaphragm was observed.ConclusionTo accurately detect hemidiaphragm paralysis, it would be interesting to combine the ultrasound study of diaphragm excursion and thickening. The different profiles reported by our study must be known to avoid misinterpretation

Multi-organ point-of-care ultrasound for COVID-19 (PoCUS4COVID): international expert consensus

COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research

Anaesth Crit Care Pain Med

Objective To develop French guidelines on the management of patients with severe abdominal trauma. Design A consensus committee of 20 experts from the French Society of Anaesthesiology and Critical Care Medicine (Société française d’anesthésie et de réanimation, SFAR), the French Society of Emergency Medicine (Société française de médecine d’urgence, SFMU), the French Society of Urology (Société française d’urologie, SFU) and from the French Association of Surgery (Association française de chirurgie, AFC), the Val-de-Grâce School (École du Val-De-Grâce, EVG) and the Federation for Interventional Radiology (Fédération de radiologie interventionnelle, FRI-SFR) was convened. Declaration of all conflicts of interest (COI) policy by all participants was mandatory throughout the development of the guidelines. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for assessment of the available level of evidence with particular emphasis to avoid formulating strong recommendations in the absence of high level. Some recommendations were left ungraded. Methods The guidelines are divided in diagnostic and, therapeutic strategy and early surveillance. All questions were formulated according to Population, Intervention, Comparison, and Outcomes (PICO) format. The panel focused on three questions for diagnostic strategy: (1) What is the diagnostic performance of clinical signs to suggest abdominal injury in trauma patients? (2) Suspecting abdominal trauma, what is the diagnostic performance of prehospital FAST (Focused Abdominal Sonography for Trauma) to rule in abdominal injury and guide the prehospital triage of the patient? and (3) When suspecting abdominal trauma, does carrying out a contrast enhanced thoraco-abdominal CT scan allow identification of abdominal injuries and reduction of mortality? Four questions dealt with therapeutic strategy: (1) After severe abdominal trauma, does immediate laparotomy reduce morbidity and mortality? (2) Does a “damage control surgery” strategy decrease morbidity and mortality in patients with a severe abdominal trauma? (3) Does a laparoscopic approach in patients with abdominal trauma decrease mortality or morbidity? and (4) Does non-operative management of patients with abdominal trauma without bleeding reduce mortality and morbidity? Finally, one question was formulated regarding the early monitoring of these patients: In case of severe abdominal trauma, which kind of initial monitoring does allow to reduce the morbi-mortality? The analysis of the literature and the recommendations were conducted following the GRADE® methodology. Results The SFAR/SFMU Guideline panel provided 15 statements on early management of severe abdominal trauma. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, five have a high level of evidence (Grade 1±), six have a low level of evidence (Grade 2±) and four are expert judgments. Finally, no recommendation was provided for one question. Conclusions Substantial agreement exists among experts regarding many strong recommendations for the best early management of severe abdominal trauma

Fluid loading therapy to prevent spinal hypotension in women undergoing elective caesarean section Network meta-analysis, trial sequential analysis and meta-regression

BACKGROUND Fluid loading is one of the recognised measures to prevent hypotension due to spinal anaesthesia in women scheduled for a caesarean section. OBJECTIVE We aimed to evaluate the current evidence on fluid loading in the prevention of spinal anaesthesia-induced hypotension. DESIGN Systematic review and network meta-analysis with trial sequential analy

La transmission du tennis en France (2015) : sociographie d’une relation de service

If, in a sociological point of view, you look at the way tennis is played in France, you can make three fundamental observations. First, it,'s a very popular hobby : in 2014 the French tennis federation (FFT) counted up to one million one hundred thousand members, making tennis the second national sport, behind the unreachable footbal. Second, this activity is now accessible to people who were rather excluded until then. This phenomenon has been quite inaccurately described as « democratization ». Finally, if you observe the clubs, you realize that more and more tennis players practice this sport under the supervision od a coach. The latter is in charge of perfecting their skills, or sometimes enven more iplicity of making their practice easier by finding them a partner or arranging a match for example. This thesis is at cross-road between a sociological analysis of leisure activities, sport, carrer, body and, above all, expertise. What is here called « the supervised practice of tennis » refers to a modern playing method that is now standard in clubs. This enquiry depicts the social mechanism that produces or enables what Erving Goffman refers to as « a service relationship » and then it use and effects from the point of view of those who experience it. This is a sociographical approach that combines a necessary detachment from the subject and a participation combined with a watchful observation from different positions. The enquiry is divided into three phases, dealing with the object from its normalization in the modern sporting landscape, to the personal experiences in which it resultsDe pertinents travaux analysent l'impact du sport dans notre société, répartissant en différentes catégories ses agents, étudiant sa marchandisation ou s'intéressant encore à ses formes les plus extrêmes, voire les plus élitistes. Mais que peut-on dire des effets produits par cet objet du point de vue de sa transmission ? Comment décrire les rapports parfois paradoxaux entre la modélisation institutionnelle de la diffusion du sport et sa réalité quotidienne ? Si plus précisément on s'intéresse à la pratique du tennis en France, il est possible d'établir trois constats fondamentaux. Premièrement, ce jeu est un loisir « majeur » : en 2014 la fédération française de tennis (FFT) comptabilisait plus d'un million de licenciés, ce qui faisait du tennis le second sport national, derrière l'intouchable football. Dans un second temps, cette activité est désormais accessible à des publics qui jusqu'ici en étaient relativement exclus. Ce phénomène fut traduit – de façon quelque peu erronée – de « démocratisation ». Enfin, lorsqu'on observe de plus près ce qui se passe dans les clubs, on s'aperçoit que les adeptes du tennis sont de plus en plus nombreux à pratiquer ce sport sous la coupe d'une sorte d' « entraineur ». Ce dernier est chargé de parfaire leur maitrise de la discipline, voire de façon plus implicite, de réduire les contraintes classiques du joueur de club (trouver un partenaire, organiser une partie, etc...). Cette thèse – à la croisée d'une sociologie du loisir, du sport, des professions, du corps et de l'expertise – s'intéresse principalement à cette dernière tendance. Ce que nous désignerons comme la « pratique encadrée du tennis » s'érige comme une modalité de jeu moderne et désormais pleinement normalisée dans les clubs. Notre enquête dresse alors la chaine sociale qui produit ou permet la tenue de ce qu'Erving Goffman désigne comme une « relation de service », avant de décrire de ses usages et de ses effets du point de vue des individus qui la vivent. La démarche est sociographique, elle conjugue une nécessaire distanciation sur l'objet et une « participation observante » établie sous différentes postures (« élève », « encadrant », observateur, ou encore simple confident). L'étude se divise en trois phases qui traitent notre objet de sa normalisation dans le paysage sportif contemporain, jusqu'aux expériences individuelles qui en émanent