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 du remaniement électronique lors de l’ionisation et application à la validité du théorème de Koopmans

On se propose de calculer, dans le cadre du champ autocohérent de HARTREE-FOCK, la correction au théorème de KOOPMANS [math] due au remaniement des orbitales lors du processus vertical d’ionisation. Le principe du calcul est de considérer la perte d’un électron comme une perturbation que subissent les orbitales de la molécule, et par suite de laquelle elles doivent se réarranger de manière cohérente. L’énergie de perturbation du deuxième ordre, compte tenu de l’effet primaire du champ du trou sur les orbitales mais en négligeant l’effet secondaire d’autocohérence des orbitales remaniées sur elles-mêmes, fournit l’énergie de remaniement, pour laquelle on donne une formule analytique. L’application à des molécules conjuguées simples conduit à une énergie de remaniement très petite, de l’ordre de — 0,10 eV. Il semble donc, du moins dans ce cas, que le fait de négliger le remaniement des orbitales ne constitue pas une limitation importante au théorème de KOOPMANS

167. 31 octobre 1986. Décret n° 86-1171 du 31 octobre 1986 relatif aux contrats entre l'État et les établissements d'enseignement supérieur privés relevant du ministère de l'Agriculture

Chirac, Guillaume François, Balladur, Monory René, Juppé Alain, Devaquet Alain. 167. 31 octobre 1986. Décret n° 86-1171 du 31 octobre 1986 relatif aux contrats entre l'État et les établissements d'enseignement supérieur privés relevant du ministère de l'Agriculture. In: L'enseignement agricole et vétérinaire de la Libération à nos jours. Textes officiels avec introduction, notes et annexes. Paris : Institut national de recherche pédagogique, 2005. pp. 745-751. (Bibliothèque de l'Histoire de l'Education, 21

167. 31 octobre 1986. Décret n° 86-1171 du 31 octobre 1986 relatif aux contrats entre l'État et les établissements d'enseignement supérieur privés relevant du ministère de l'Agriculture

Chirac, Guillaume François, Balladur, Monory René, Juppé Alain, Devaquet Alain. 167. 31 octobre 1986. Décret n° 86-1171 du 31 octobre 1986 relatif aux contrats entre l'État et les établissements d'enseignement supérieur privés relevant du ministère de l'Agriculture. In: L'enseignement agricole et vétérinaire de la Libération à nos jours. Textes officiels avec introduction, notes et annexes. Paris : Institut national de recherche pédagogique, 2005. pp. 745-751. (Bibliothèque de l'Histoire de l'Education, 21

Hyperoxia and hypertonic saline in patients with septic shock (HYPERS2S): a two-by-two factorial, multicentre, randomised, clinical trial

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In-Hospital Mortality-Associated Factors of Thrombotic Antiphospholipid Syndrome Patients Requiring Intensive Care Unit Admission

International audienceBackground: The antiphospholipid syndrome (APS) is a systemic autoimmune disease defined by thrombotic events that can require ICU admission because of organ dysfunction related to macrovascular and/or microvascular thrombosis. Critically ill patients with thrombosis and APS were studied to gain insight into their prognoses and in-hospital mortality-associated factors.Methods: This French national, multicenter, retrospective study included all patients with APS and any new thrombotic manifestations admitted to 24 ICUs (January 2000-September 2018).Results: During the study period, 134 patients (male/female ratio, 0.4) with 152 APS episodes were admitted to the ICU (mean age at admission, 46.0 ± 15.1 years). In-hospital mortality of their 134 last episodes was 35 of 134 (26.1%). The Cox multivariable model retained certain factors (hazard ratio [95% CI]: age ≥ 40 years, 11.4 [3.1-41.5], P < .0001; mechanical ventilation, 11.0 [3.3-37], P < .0001; renal replacement therapy, 2.9 [1.3-6.3], P = .007; and in-ICU anticoagulation, 0.1 [0.03-0.3], P < .0001) as independently associated with in-hospital mortality. For the subgroup of definite/probable catastrophic APS, the Cox bivariable model (including the Simplified Acute Physiology Score II score) retained double therapy (corticosteroids + anticoagulant, 0.2 [0.07-0.6]; P = .005) but not triple therapy (corticosteroids + anticoagulant + IV immunoglobulins or plasmapheresis: hazard ratio, 0.3 [0.1-1.1]; P = .07) as independently associated with in-hospital mortality.Conclusions: In-ICU anticoagulation was the only APS-specific treatment independently associated with survival for all patients. Double therapy was independently associated with better survival of patients with definite/probable catastrophic APS. In these patients, further studies are needed to determine the role of triple therapy

Prevalence, characteristics and outcome of cardiac manifestations in critically-ill antiphospholipid syndrome patients

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High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure

BACKGROUND: Whether noninvasive ventilation should be administered in patients with acute hypoxemic respiratory failure is debated. Therapy with high-flow oxygen through a nasal cannula may offer an alternative in patients with hypoxemia. METHODS: We performed a multicenter, open-label trial in which we randomly assigned patients without hypercapnia who had acute hypoxemic respiratory failure and a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen of 300 mm Hg or less to high-flow oxygen therapy, standard oxygen therapy delivered through a face mask, or noninvasive positive-pressure ventilation. The primary outcome was the proportion of patients intubated at day 28; secondary outcomes included all-cause mortality in the intensive care unit and at 90 days and the number of ventilator-free days at day 28. RESULTS: A total of 310 patients were included in the analyses. The intubation rate (primary outcome) was 38% (40 of 106 patients) in the high-flow-oxygen group, 47% (44 of 94) in the standard group, and 50% (55 of 110) in the noninvasive-ventilation group (P = 0.18 for all comparisons). The number of ventilator-free days at day 28 was significantly higher in the high-flow-oxygen group (24±8 days, vs. 22±10 in the standard-oxygen group and 19±12 in the noninvasive-ventilation group; P = 0.02 for all comparisons). The hazard ratio for death at 90 days was 2.01 (95% confidence interval [CI], 1.01 to 3.99) with standard oxygen versus high-flow oxygen (P = 0.046) and 2.50 (95% CI, 1.31 to 4.78) with noninvasive ventilation versus high-flow oxygen (P = 0.006). CONCLUSIONS: In patients with nonhypercapnic acute hypoxemic respiratory failure, treatment with high-flow oxygen, standard oxygen, or noninvasive ventilation did not result in significantly different intubation rates. There was a significant difference in favor of high-flow oxygen in 90-day mortality. (Funded by the Programme Hospitalier de Recherche Clinique Interrégional 2010 of the French Ministry of Health; FLORALI ClinicalTrials.gov number, NCT01320384.

The Clinical Picture of Severe Systemic Capillary-Leak Syndrome Episodes Requiring ICU Admission

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