Changes in Heart Rate Variability Recorded in Natural Situation with T-Shirt Integrated Sensors and Level of Observed Behavioral Excitation: A Pilot Study of Patients with Intellectual Disabilities and Psychiatric Disorders.

The present study investigates the possibilities of using heart rate variability (HRV) parameters as physiological markers that precede increase in observed behavioral excitation of intellectually disabled individuals. The ability to recognize or predict such patterns, especially in patients showing unpredictable reactions and language deficiencies, might be a major step forward in clinical research. Thirteen volunteers with intellectual disabilities, who had suffered of at least one event of overt aggression in the preceding 3 months, participated to the study. The protocol consists in the acquisition of continuous electrocardiogram (ECG) throughout approximately two times of 8 h in natural situation, using a T-shirt integrated with sensors. Simultaneously, an observer evaluates the patient's level of overt excitation from calm (level 1) to extremely tense (level 5) and send online via Bluetooth these triggers into the ECG signals. The HRV indexes were then estimated offline on the basis of the inter-beat intervals recorded by the ECG, independently for the 30 min preceding each behavioral tension marking point, averaged, and compared through non-parametric Wilcoxon matched-pairs test. Of these, the RMSSD and LF/HF calculations were used to observe the fluctuations of inhibitory activity and cardiovagal balance through different tension states. Seven individuals have sufficient reliable data for analysis. They have reached at least a level 3 of behavioral excitation (moderately tense) or more (very to extremely tense, level 4 and 5) and have been retained for further analysis. In sum, a total of 197 periods of tension were kept, made up of 46 periods of slight excitation (level 2), 18 of moderate excitation (level 3), 10 of high excitation (level 4), and 5 of extreme agitation (level 5). Variations in the HRV as a function of degree of excitation are observed for RMSSD index only (inhibitory parasympathetic activity). The changes from calm to increasing levels of excitation are characterized by a significant downfall in RMSSD index when patients were evaluated to be in a very high level of tension (level 4). The presence of precursors to agitation, reflected in the falling-off of parasympathetic activity, offers potentially interesting prospects for therapeutic development

Usefulness of routine preoperative testing in a developing country: a prospective study

Introduction: The assessment of anesthetic risks is an essential component of preoperative evaluation. In developing world, preanesthesia evaluation may be challenging because patient's medical history and records are scare, and language barrier limits physical examination. Our objective was to evaluate the impact of routine preoperative testing in a low-resources setting. Methods: Prospective observational study performed in a French forward surgical unit in Abidjan, Ivory Coast. 201 patients who were scheduled for non urgent surgery were screened with routine laboratory exams during preoperative evaluation. Changes in surgery were assessed (delayed or scheduled). Results: Abnormal hemoglobin findings were reported in 35% of patients, abnormal WBC count in 11,1% of patients, abnormal platelets in 15,3% of patients. Positive HIV results were found in 8,3% of cases. Routine tests represented 43,6% of changes causes. Conclusion: Our study showed that in a developing country, routine preoperative tests showed abnormal results up to 35% of cases, and represented 43,6% of delayed surgery causes. The rate of tests leading to management changes varied widely, from 0% to 8,3%. These results suggested that selected tests would be useful to diagnose diseases that required treatment before non urgent surgery. However, larger studies are needeed to evaluate the cost/benefit ratio and the clinical impact of such a strategy

Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome associated with COVID-19: An Emulated Target Trial Analysis.

RATIONALE: Whether COVID patients may benefit from extracorporeal membrane oxygenation (ECMO) compared with conventional invasive mechanical ventilation (IMV) remains unknown. OBJECTIVES: To estimate the effect of ECMO on 90-Day mortality vs IMV only Methods: Among 4,244 critically ill adult patients with COVID-19 included in a multicenter cohort study, we emulated a target trial comparing the treatment strategies of initiating ECMO vs. no ECMO within 7 days of IMV in patients with severe acute respiratory distress syndrome (PaO2/FiO2 <80 or PaCO2 ≥60 mmHg). We controlled for confounding using a multivariable Cox model based on predefined variables. MAIN RESULTS: 1,235 patients met the full eligibility criteria for the emulated trial, among whom 164 patients initiated ECMO. The ECMO strategy had a higher survival probability at Day-7 from the onset of eligibility criteria (87% vs 83%, risk difference: 4%, 95% CI 0;9%) which decreased during follow-up (survival at Day-90: 63% vs 65%, risk difference: -2%, 95% CI -10;5%). However, ECMO was associated with higher survival when performed in high-volume ECMO centers or in regions where a specific ECMO network organization was set up to handle high demand, and when initiated within the first 4 days of MV and in profoundly hypoxemic patients. CONCLUSIONS: In an emulated trial based on a nationwide COVID-19 cohort, we found differential survival over time of an ECMO compared with a no-ECMO strategy. However, ECMO was consistently associated with better outcomes when performed in high-volume centers and in regions with ECMO capacities specifically organized to handle high demand. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Étude Hypno-Séno : anesthésie générale versus hypno-tumescence en chirurgie mammaire conservatrice : évaluation de la qualité des marges de résection chirurgicale

Hypnosis is often proposed to patients in the comprehensive care of breast cancer. Many studies have evaluated the benefit of a preoperative hypnosis session. There is a lack of literature evaluating the performance of breast surgery under local anaesthesia associated with hypnosis. Since July 2017 the Grenoble-Alpes University Hospital Center (CHUGA) performs conservative breast surgery under hypno-tumescence. The operation is performed under hypnosis and local anesthesia by injecting 100 to 1000 ml of lidocaine into the surgical area. This technique can modify the anatomical positions and make surgery more difficult. The main outcome of our study is to show that the carcinological quality of surgical management under hypno-tumescence and sedation is no different from standard management under general anaesthesia. Material and method: After approval by the hospital's ethics committee, protocol MR-004, we conducted a retrospective study, at the CHUGA, from July 2017 to December 2019, comparing the number of surgical re-excision for positive margins of conservative breast surgeries performed under hypnosis to those performed under general anesthesia. To improve comparability between groups, patients were matched by a propensity score. Results: The number of re-excision in the hypno-tumescence group was 7/38 (9.2%) patients and 7/38 (9.2%) patients in the general anesthesia group. There was no statistically significant difference. The overall re-excision rate is 18.4%. Discussion: Our study is the first to evaluate the quality of carcinological resection under hypno-tumescence compared to standard management and shows that there is no significant difference between the two groups.L'hypnose est proposée aux patientes dans le cadre d'une prise en charge globale en cancérologie mammaire. Depuis juillet 2017 le centre hospitalo-universitaire de Grenoble-Alpes (CHUGA) réalise des chirurgies mammaires conservatrices sous hypno-tumescence. Les objectifs d'une chirurgie mammaire conservatrice sont de réséquer la tumeur en obtenant des marges d'exérèse in sano et de respecter au maximum le parenchyme sain afin d'avoir un résultat esthétique optimal. La tumescence consiste en l'injection de 100 à 1000 ml de sérum lidocaïné dans la zone opératoire. Cette technique peut modifier les rapports anatomiques et rendre la chirurgie plus difficile. L'objectif principal de notre étude est de montrer que la qualité carcinologique de la prise en charge chirurgicale sous hypno-tumescence et sédation n'est pas différente par rapport à une prise en charge standard sous anesthésie générale. Après accord du comité d'éthique de l'hôpital, protocole MR-004, nous avons réalisé une étude rétrospective, au CHUGA, de juillet 2017 à décembre 2019, comparant le nombre de reprises chirurgicales pour marge d'exérèse non in sano des chirurgies mammaires conservatrices réalisées sous hypnose à celles pratiquées sous anesthésie générale. Afin d'améliorer la comparabilité entre les groupes, les patientes ont été appariées par un score de propension. Le nombre de reprises dans le groupe hypno-tumescence est de 7/38 (9,2%) patientes et de 7/38 (9,2%) patientes dans le groupe anesthésie générale. Il n'y a pas de différence statistiquement significative. Le taux de reprise globale est de 18.4%. Notre étude est la première, à notre connaissance, à étudier la qualité de la résection carcinologique sous hypno-tumescence par rapport à une prise en charge standard et montre qu’il n’y a pas de différence significative entre les deux groupes