ABSTRACT:Congenital thrombotic thrombocytopenic purpura (cTTP) is caused by a severe inherited ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 motif, member 13) deficiency. Although acute episodes are life-threatening, long-term burden of ischemic complications, and effectiveness of prophylactic strategies remain underexplored. We conducted a 25-year national, multicenter study of 88 patients with cTTP enrolled in the French Thrombotic Microangiopathy registry. Patients were stratified by age and clinical context at disease onset: pediatric (n = 42), pregnancy (n = 33), and adult onset (n = 13). Clinical features, genotypes, treatment regimens, and long-term ischemic outcomes were analyzed. Pediatric patients exhibited early-onset disease (median age at diagnosis, 2 years [interquartile range, 0-13]) with recurrent episodes and a high burden of neurological complications. In patients with pregnancy-onset disease, no relapses were observed outside pregnancy. Adult-onset patients, typically diagnosed aged >50 years, showed prevalent cardiovascular disease, stroke, and kidney injury. Mental health disorders were common across all groups. Despite long-term plasma prophylaxis, organ dysfunction persisted, particularly in pediatric- and adult-onset groups. In pregnancy-onset cTTP, tailored midterm prophylaxis during pregnancy reduced maternal and fetal complications. Thirty-nine patients received recombinant human ADAMTS13 (rhADAMTS13) prophylaxis (median follow-up, 5 months [interquartile range, 6-17]). Prophylactic treatment significantly improved relapse-free survival, with a comparable outcome using intensive plasma-derived products and rhADAMTS13 in pediatric-onset cases, although adverse events were more prevalent using plasma therapy. Our findings highlight the clinical and genetic heterogeneity of cTTP and the burden of organ dysfunction. Intensive prophylaxis improves relapse-free survival. rhADAMTS13 represents a safe and promising first-line option that should help reduce long-term organ damage and improve quality of life.

BACKGROUND:Brain death after hanging-induced cardiac arrest is a fatal complication about which few data are available. We aimed at identifying the early predictors of progression to brain death in patients with hanging-induced cardiac arrest. METHODS:Retrospective study including adults with return of spontaneous circulation from hanging-induced cardiac arrest admitted to 34 ICUs in France and Belgium between 2000 and 2024. Logistic multivariate regression was performed to identify factors associated with progression to brain death. RESULTS:Of the 554 patients with hanging-induced cardiac arrest, brain imaging was performed on admission in 443 (80.0%) patients. Overall, 169/554 (30.5%) and 142/443 (32.1%) patients progressed to brain death within a median time of 3 days, and up to 12 days, after the hanging-induced cardiac arrest. In 443 patients with brain imaging, five factors were independently associated with a higher risk of progression to brain death: female (OR, 1.76; 95% CI, 1.06-2.90; p = 0.03), asystole as first recorded rhythm (OR, 2.03; 95% CI, 1.27-3.29; p = 0.004), low-flow time > 30 min (OR, 1.84; 95% CI, 1.07-3.17; p = 0.03), total Logistic Organ Dysfunction System Score at day 1 (OR, 1.93/per point; 95% CI, 1.14-3.29; p = 0.02), and cerebral oedema and/or ischemic complication on brain CT scan at ICU admission (OR, 1.62; 95% CI, 1.01-2.61, p = 0.04). Conversely, age > 50 years (OR, 0.59; 95%CI, 0.35-0.98, p = 0.04) and status myoclonus ≤ day 2 (OR, 0.24; 95%CI, 0.09-0.54, p = 0.001) were associated with a lower risk of progression to brain death after hanging-induced cardiac arrest. CONCLUSION:Our findings emphasise the very high rate of brain death after hanging-induced cardiac arrest. In our population, factors associated with brain death after hanging induced cardiac arrest predominantly reflect initial injury severity.

La réanimation, bien que spécialité récente, est un terreau fertile à la fois pour les innovations technologiques mais aussi le développement d’un stress au travail en raison de ses spécificités. L’implémentation progressive de l’Intelligence Artificielle (IA) modifiera significativement les conditions de travail de l’ensemble des soignants en soins critiques. Il est indispensable de s’interroger sur les conséquences que pourrait avoir l’IA sur la QVCT. S’il n’y a encore que peu d’études s’intéressant spécifiquement au lien qui réunit QVCT et IA, celui-ci pourrait s’avérer positif. Cette dernière pourrait ainsi jouer un rôle d’acteur par une amélioration des conditions de travail en diminuant la charge de travail, augmentant les compétences de l’utilisateur, son degré d’autonomie et ses responsabilités. Un autre positionnement de cette technologie peut s’envisager comme outil d’évaluation de la QVCT même si cela reste encore au stade expérimental. Outil d’une puissance encore difficilement mesurable, l’IA pourrait tout autant nuire à cette dernière. Il est ainsi indispensable que l’intégration à venir soit accompagnée d’études sur ses conséquences possibles sur la QVCT.

Millions of households have cats or dogs as pets, and infections due to bites or scratches are increasing, with the most common pathogens being Pasteurella spp., Bartonella spp., Capnocytophaga spp, and Francisella tularensis. The objective of this study was to describe patients admitted to the intensive care unit (ICU) for infection transmitted by cats or dogs, as well as their outcomes. The retrospective multicentre observational cohort study PETSEPSIS included consecutive adults admitted to 46 ICUs in France between 2009 and 2019 for sepsis due to cat or dog bites and/or caused by any of the four above-listed bacteria. We described their features and outcomes and performed univariate and multivariate analyses to identify factors associated with death. We included 174 patients with a median age of 64 [50–74] years; 58.1

The increase in worldwide travel is making imported malaria a growing health concern in non-endemic countries. Most data on the pathophysiology of malaria come from endemic areas. Little is known about cytokine profiles during imported malaria. This study aimed at deciphering the relationship between cytokine host response and malaria severity among imported cases in France. This study reports cytokine profiles in adults with Plasmodium falciparum malaria included in the PALUREA prospective study conducted between 2006 and 2010. The patients were classified as having uncomplicated malaria (UM) or severe malaria (SM), with this last further categorized as very severe malaria (VSM) or less severe malaria (LSM). At hospital admission, eight blood cytokines were assayed in duplicate using Luminex ® technology: interleukin (IL)-1α, IL-1β, IL-2, IL-4, IL-10, tumor necrosis factor (TNF)α, interferon (IFN)γ, and macrophage migration inhibitory factor (MIF). These assays were repeated on days 1 and 2 in the SM group. Of the 278 patients, 134 had UM and 144 SM. At hospital admission, over half the patients had undetectable levels of IL-1α, IL-1β, IL-2, IL-4, IFNγ, and TNFα, while IL-10 and MIF were significantly higher in the SM vs. the UM group. Higher IL-10 was significantly associated with higher parasitemia (R = 0.32 [0.16–0.46]; P = 0.0001). In the SM group, IL-10 elevation persisting from admission to day 2 was significantly associated with subsequent nosocomial infection. Of eight tested cytokines, only MIF and IL-10 were associated with disease severity in adults with imported P. falciparum malaria. At admission, many patients had undetectable cytokine levels, suggesting that circulating cytokine assays may not be helpful as part of the routine evaluation of adults with imported malaria. Persisting high IL-10 concentration was associated with subsequent nosocomial infection, suggesting its possible interest in immune monitoring of most severe patients.

BackgroundCardiac arrest is the most life-threatening complication of attempted suicide by hanging. However, data are scarce on its characteristics and outcome predictors.MethodsThis retrospective observational multicentre study in 31 hospitals included consecutive adults admitted after cardiac arrest induced by suicidal hanging. Factors associated with in-hospital mortality were identified by multivariate logistic regression with multiple imputations for missing data and adjusted to the temporal trends over the study period.ResultsOf 450 patients (350 men, median age, 43 [34–52] years), 305 (68%) had a psychiatric history, and 31 (6.9%) attempted hanging while hospitalized. The median time from unhanging to cardiopulmonary resuscitation was 0 [0–5] min, and the median time to return of spontaneous circulation (ROSC) was 20 [10–30] min. Seventy-nine (18%) patients survived to hospital discharge. Three variables were independently associated with higher in-hospital mortality: time from collapse or unhanging to ROSC>20 min (odds ratio [OR], 4.71; 95% confidence intervals [95%CIs], 2.02–10.96; p = 0.0004); glycaemia >1.4 g/L at admission (OR, 6.38; 95%CI, 2.60–15.66; p < 0.0001); and lactate >3.5 mmol/L at admission (OR, 6.08; 95%CI, 1.71–21.06; p = 0.005). A Glasgow Coma Scale (GCS) score of >5 at admission was associated with lower in-hospital mortality (OR, 0.009; 95%CI, 0.02–0.37; p = 0.0009).ConclusionIn patients with hanging-induced cardiac arrest, time from collapse or unhanging to return of spontaneous circulation, glycaemia, arterial lactate, and coma depth at admission were independently associated with survival to hospital discharge. Knowledge of these risk factors may help guide treatment decisions in these patients at high risk of hospital mortality.

Background:The prevalence, prognostic role, and diagnostic value of blood pressure in immune-mediated thrombotic thrombocytopenic purpura (iTTP) and other thrombotic microangiopathies (TMAs) remain unclear.Methods:Using a national cohort of iTTP (n = 368), Shigatoxin-induced hemolytic uremic syndrome (n = 86), atypical hemolytic uremic syndrome (n = 84), and hypertension-related thrombotic microangiopathy (n = 25), we sought to compare the cohort's blood pressure profile to assess its impact on prognosis and diagnostic performances.Results:Patients with iTTP had lower blood pressure than patients with other TMAs, systolic (130 [interquartile range (IQR) 118-143] vs 161 [IQR 142-180] mmHg) and diastolic (76 [IQR 69-83] vs 92 [IQR 79-105] mmHg, both p < 0.001). The best threshold for iTTP diagnosis corresponded to a systolic blood pressure <150 mmHg. iTTP patients presenting with hypertension had a significantly poorer survival (hazard ratio 1.80, 95% confidence interval 1.07-3.04), and this effect remained significant after multivariable adjustment (hazard ratio = 1.14, 95% confidence interval 1.00-1.30). Addition of a blood pressure criterion modestly improved the French clinical score to predict a severe A disintegrin and metalloprotease with thrombospondin type 1 deficiency in patients with an intermediate score (i.e., either platelet count <30 × 109/L or serum creatinine <200 µM).Conclusions:Elevated blood pressure at admission affects the prognosis of iTTP patients and may help discriminate them from other TMA patients. Particular attention should be paid to blood pressure and its management in these patients.

Purpose: To evaluate whether the changes in arterial pulse pressure (PP) and/or pulse pressure variation (PPV) during passive leg raising (PLR) can be used to evaluate preload responsiveness in patients with spontaneous breathing activity. Materials and methods: Patients ventilated with pressure support mode or totally spontaneously breathing were prospectively included. The values of PP and PPV were recorded before and at the end of PLR. The changes in cardiac index (CI) or the velocity-time integral (VTI) of the left ventricular outflow tract during PLR were tracked by the pulse contour analysis or transthoracic echocardiography. Patients exhibiting an increase in CI >= 10% or VTI >= 12% during PLR were defined as preload responders. Results: Among 33 patients included, 28 (80%) received norepinephrine and 14 were preload responders. The in-crease in PP > 2 mmHg in absolute value (4% in percentage) during PLR (PLRPP) predicted preload responsiveness with an area under the receiver operating characteristic (AUROC) of 0.76 +/- 0.09 (p = 0.003 vs. AUROC of 0.5). The changes in PPV during PLR, however, failed to predict preload responsiveness (p = 0.82 vs. AUROC of 0.5). Conclusion: In patients with full spontaneous breathing activity, PLR-induced changes in PP had a fair ability to assess preload responsiveness even when norepinephrine was administered. (C) 2022 Elsevier Inc. All rights reserved.

Purpose Identifying patients who will receive renal replacement therapy (RRT) during intensive care unit (ICU) stay is a major challenge for intensivists. The objective of this study was to evaluate the performance of physicians in predicting the need for RRT at ICU admission and at acute kidney injury (AKI) diagnosis. Methods Prospective, multicenter study including all adult patients hospitalized in 16 ICUs in October 2020. Physician prediction was estimated at ICU admission and at AKI diagnosis, according to a visual Likert scale. Discrimination, risk stratification and benefit of physician estimation were assessed. Mixed logistic regression models of variables associated with risk of receiving RRT, with and without physician estimation, were compared. Results Six hundred and forty-nine patients were included, 270 (41.6%) developed AKI and 77 (11.8%) received RRT. At ICU admission and at AKI diagnosis, a model including physician prediction, the experience of the physician, SOFA score, serum creatinine and diuresis to determine need for RRT performed better than a model without physician estimation with an area under the ROC curve of 0.90 [95% CI 0.86–0.94, p < 0.008 (at ICU admission)] and 0.89 [95% CI 0.83–0.93, p = 0.0014 (at AKI diagnosis)]. In multivariate analysis, physician prediction was strongly associated with the need for RRT, independently of creatinine levels, diuresis, SOFA score and the experience of the doctor who made the prediction. Conclusion As physicians are able to stratify patients at high risk of RRT, physician judgement should be taken into account when designing new randomized studies focusing on RRT initiation during AKI.

Background The presence of bacteraemia in pneumococcal pneumonia in critically ill patients does not appear to be a strong independent prognostic factor in the existing literature. However, there may be a specific pattern of factors associated with mortality for ICU patients with bacteraemic pneumococcal community-acquired pneumonia (CAP). We aimed to compare the factors associated with mortality, according to the presence of bacteraemia or not on admission, for patients hospitalised in intensive care for severe pneumococcal CAP. Methods This was a post hoc analysis of data from the prospective, observational, multicentre STREPTOGENE study in immunocompetent Caucasian adults admitted to intensive care in France between 2008 and 2012 for pneumococcal CAP. Patients were divided into two groups based on initial blood culture (positive vs. negative) for Streptococcus pneumoniae . The primary outcome was hospital mortality, which was compared between the two groups using odds ratios according to predefined variables to search for a prognostic interaction present in bacterial patients but not non-bacteraemic patients. Potential differences in the distribution of serotypes between the two groups were assessed. The prognostic consequences of the presence or not of initial bi-antibiotic therapy were assessed, specifically in bacteraemic patients. Results Among 614 included patients, 274 had a blood culture positive for S. pneumoniae at admission and 340 did not. The baseline difference between the groups was more frequent leukopaenia (26% vs. 14%, p = 0.0002) and less frequent pre-hospital antibiotic therapy (10% vs. 16.3%, p = 0.024) for the bacteraemic patients. Hospital mortality was not significantly different between the two groups ( p = 0.11). We did not observe any prognostic factors specific to the bacteraemic patient population, as the statistical comparison of the odds ratios, as an indication of the association between the predefined prognostic parameters and mortality, showed them to be similar for the two groups. Bacteraemic patients more often had invasive serotypes but less often serotypes associated with high case fatality rates ( p = 0.003). The antibiotic regimens were similar for the two groups. There was no difference in mortality for patients in either group given a beta-lactam alone vs. a beta-lactam combined with a macrolide or fluoroquinolone. Conclusion Bacteraemia had no influence on the mortality of immunocompetent Caucasian adults admitted to intensive care for severe pneumococcal CAP, regardless of the profile of the associated prognostic factors.

"Can multiple-dose activated charcoal induce elevation in blood lactate concentration? A case report." Clinical Toxicology, 59(8), pp. 761–762

Background: Pulse pressure variation (PPV) is not reliable in predicting preload responsiveness in patients receiving mechanical with spontaneous breathing (SB) activity. We hypothesised that an increase in PPV after a tidal volume (V-T) challenge (TVC) or a decrease in PPV during passive leg raising (PLR) can predict preload responsiveness in such cases. Methods: This prospective observational study was performed in two ICUs and included patients receiving mechanical ventilation with SB, for whom the treating physician decided to test preload responsiveness. Transthoracic echocardiography was used to measure the velocityetime integral (VTI) of the left ventricular outflow tract. Patients exhibiting an increase in VTI >= 12% during PLR were defined as PLR+ patients (or preload responders). Then, a TVC was performed by increasing V-T by 2 ml kg(-1) predicted body weight (PBW) for 1 min. PPV was recorded at each step. Results: Fifty-four patients (Simplified Acute Physiology Score II: 60 (25) ventilated with a V-T of 6.5 (0.8) ml kg(-1) PBW, were included. Twenty-two patients were PLR+. The absolute decrease in PPV during PLR and the absolute increase in PPV during TVC discriminated between PLR+ and PLRe patients with area under the receiver operating characteristic (AUROC) curve of 0.78 and 0.73, respectively, and cut-off values of e1% and +2%, respectively. Those AUROC curve values were similar but were significantly different from that of baseline PPV (0.61). Conclusion: In patients undergoing mechanical ventilation with SB activity, PPV does not predict preload responsiveness. However, the decrease in PPV during PLR and the increase in PPV during a TVC help discriminate preload responders from non-responders with moderate accuracy.

Abstract Background : The presence of bacteraemia in pneumococcal pneumonia in critically ill patient does not appear to be a strong prognostic factor on its own from the existing literature, but there may be a specific pattern of factors associated with mortality in ICU patients with bacteraemic pneumococcal pneumococcal community-acquired pneumonia (CAP).We aimed to identify factors associated with mortality in patients admitted to intensive care for severe bacteraemic CAP. Methods : This is a post-hoc analysis of data from the prospective, observational, multicentre STREPTOGENE study in immunocompetent Caucasian adults admitted to intensive care in France, between 2008 and 2012, for bacteraemic pneumococcal CAP documented by culture and/or urinary antigenuria. Patients were divided into two groups based on initial blood culture positivity for Streptococcus pneumoniae . The primary outcome was hospital mortality. Serotypes of 339 S. pneumoniae strains were determined. Results : Of 614 included patients, 274 did and 340 did not have a blood culture positive for S. pneumoniae at admission. The only baseline difference between the groups was more frequent leukopenia in bacteraemic patients (26% vs. 14%, p =0.0002). Hospital mortality was not significantly different between groups ( p =0.11). The associations between the various prognostic parameters studied and mortality were similar in the two groups. Bacteraemic patients more often had invasive serotypes but less often had serotypes associated with high case-fatality rates ( p =0.003). Antibiotic regimens were similar in the two groups. In neither group was mortality different in patients given a beta-lactam alone vs. a beta-lactam combined with a macrolide or fluoroquinolone. Interpretation : In immunocompetent Caucasian adults admitted to intensive care for severe pneumococcal CAP, bacteraemia had no influence on mortality, regardless of the prognostic factor profile. A prospective randomised trial is warranted to confirm the absence of superiority of one treatment over others.

Background Poisoning is one of the leading causes of admission to the emergency department and intensive care unit. A large number of epidemiological changes have occurred over the last years such as the exponential growth of new synthetic psychoactive substances. Major progress has also been made in analytical screening and assays, enabling the clinicians to rapidly obtain a definite diagnosis. Methods A committee composed of 30 experts from five scientific societies, the Société de Réanimation de Langue Française (SRLF), the Société Française de Médecine d’Urgence (SFMU), the Société de Toxicologie Clinique (STC), the Société Française de Toxicologie Analytique (SFTA) and the Groupe Francophone de Réanimation et d’Urgences Pédiatriques (GFRUP) evaluated eight fields: (1) severity assessment and initial triage; (2) diagnostic approach and role of toxicological analyses; (3) supportive care; (4) decontamination; (5) elimination enhancement; (6) place of antidotes; (7) specificities related to recreational drug poisoning; and (8) characteristics of cardiotoxicant poisoning. Population, Intervention, Comparison, and Outcome (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Analysis of the literature and formulation of recommendations were then conducted according to the GRADE ® methodology. Results The SRLF-SFMU guideline panel provided 41 statements concerning the management of pharmaceutical and recreational drug poisoning. Ethanol and chemical poisoning were excluded from the scope of these recommendations. After two rounds of discussion and various amendments, a strong consensus was reached for all recommendations. Six of these recommendations had a high level of evidence (GRADE 1±) and six had a low level of evidence (GRADE 2±). Twenty-nine recommendations were in the form of expert opinion recommendations due to the low evidences in the literature. Conclusions The experts reached a substantial consensus for several strong recommendations for optimal management of pharmaceutical and recreational drug poisoning, mainly regarding the conditions and effectiveness of naloxone and N -acetylcystein as antidotes to treat opioid and acetaminophen poisoning, respectively.