François Hemery

Effects of hydroxyethylstarch and gelatin on renal function in severe sepsis: a multicentre randomised study

BACKGROUNDnHydroxyethylstarch used for volume restoration in brain-dead kidney donors has been associated with impaired kidney function in the transplant recipients. We undertook a multicentre randomised study to assess the frequency of acute renal failure (ARF) in patients with severe sepsis or septic shock treated with hydroxyethylstarch or gelatin.nnnMETHODSnAdults with severe sepsis or septic shock were enrolled prospectively in three intensive-care units in France. They were randomly assigned 6% hydroxyethylstarch (200 kDa, 0.60-0.66 substitution) or 3% fluid-modified gelatin. The primary endpoint was ARF (a two-fold increase in serum creatinine from baseline or need for renal replacement therapy). Analyses were by intention to treat.nnnFINDINGSn129 patients were enrolled over 18 months. Severity of illness and serum creatinine (median 143 [IQR 88-203] vs 114 [91-175] micromol/L) were similar at baseline in the hydroxyethylstarch and gelatin groups. The frequencies of ARF (27/65 [42%] vs 15/64 [23%], p=0.028) and oliguria (35/62 [56%] vs 23/63 [37%], p=0.025) and the peak serum creatinine concentration (225 [130-339] vs 169 [106-273] micromol/L, p=0.04) were significantly higher in the hydroxyethylstarch group than in the gelatin group. In a multivariate analysis, risk factors for acute renal failure included mechanical ventilation (odds ratio 4.02 [95% CI 1.37-11.8], p=0.013) and use of hydroxyethylstarch (2.57 [1.13-5.83], p=0.026).nnnINTERPRETATIONSnThe use of this preparation of hydroxyethylstarch as a plasma-volume expander is an independent risk factor for ARF in patients with severe sepsis or septic shock.

Risk stratification of early admission to the intensive care unit of patients with no major criteria of severe community-acquired pneumonia: development of an international prediction rule.

IntroductionTo identify risk factors for early (< three days) intensive care unit (ICU) admission of patients hospitalised with community-acquired pneumonia (CAP) and not requiring immediate ICU admission, and to stratify the risk of ICU admission on days 1 to 3.MethodsUsing the original data from four North American and European prospective multicentre cohort studies of patients with CAP, we derived and validated a prediction rule for ICU admission on days 1 to 3 of emergency department (ED) presentation, for patients presenting with no obvious reason for immediate ICU admission (not requiring immediate respiratory or circulatory support).ResultsA total of 6560 patients were included (4593 and 1967 in the derivation and validation cohort, respectively), 303 (4.6%) of whom were admitted to an ICU on days 1 to 3. The Risk of Early Admission to ICU index (REA-ICU index) comprised 11 criteria independently associated with ICU admission: male gender, age younger than 80 years, comorbid conditions, respiratory rate of 30 breaths/minute or higher, heart rate of 125 beats/minute or higher, multilobar infiltrate or pleural effusion, white blood cell count less than 3 or 20 G/L or above, hypoxaemia (oxygen saturation < 90% or arterial partial pressure of oxygen (PaO2) < 60 mmHg), blood urea nitrogen of 11 mmol/L or higher, pH less than 7.35 and sodium less than 130 mEq/L. The REA-ICU index stratified patients into four risk classes with a risk of ICU admission on days 1 to 3 ranging from 0.7 to 31%. The area under the curve was 0.81 (95% confidence interval (CI) = 0.78 to 0.83) in the overall population.ConclusionsThe REA-ICU index accurately stratifies the risk of ICU admission on days 1 to 3 for patients presenting to the ED with CAP and no obvious indication for immediate ICU admission and therefore may assist orientation decisions.

Constant flow insufflation of oxygen as the sole mode of ventilation during out-of-hospital cardiac arrest

BackgroundConstant flow insufflation of oxygen (CFIO) through axa0Boussignac multichannel endotracheal tube has been reported to be an efficient ventilatory method during chest massage for cardiac arrest.MethodsPatients resuscitated for out-of-hospital cardiac arrest were randomly assigned to standard endotracheal intubation and mechanical ventilation (MV; nu202f=u202f457) or use of CFIO at axa0flow rate of 15u202fl/min (nu202f=u202f487). Continuous chest compressions were similar in the two groups. Pulse oximetry level was recorded every 5u202fmin. Outcome of initial resuscitation, hospital admission, complications, and discharge from the intensive care unit (ICU) were analyzed. The randomization scheme was changed during the study, but the in-depth analysis was performed only on the first cohort of 341 patients with CFIO and 355 with MV, because of randomization problems in the second part.ResultsNo difference in outcome was noted regarding return to spontaneous circulation (CFIO 21%, MV 20%), hospital admission (CFIO 17%, MV 16%), or ICU discharge (CFIO 2.4%, MV 2.3%). The level of detectable pulse saturation and the proportion of patients with saturation above 70% were higher with CFIO. Ten patients with MV but only one with CFIO had rib fractures.ConclusionsCFIO is axa0simplified alternative to MV, with favorable effects regarding oxygenation and fewer complications, as observed in this group of patients with desperate prognosis.

Impact of a computer-generated alert system prompting review of antibiotic use in hospitals

OBJECTIVESnThe aim of this study was to measure the impact on antibiotic use of a computer-generated alert prompting post-prescription review and direct counselling in hospital wards.nnnMETHODSnA computer-generated alert on new prescriptions of 15 antibiotics was reviewed weekly by an infectious disease physician for 41 weeks. During the first 6 months of the study, criteria selected for potential intervention were: (i) a planned duration of treatment of > or =10 days; (ii) discordance between the spectrum of the prescribed antibiotic and available microbiological results; or (iii) prescriptions of broad-spectrum beta-lactams, fluoroquinolones, glycopeptides or linezolid. During the following 5 months, the alert was restricted to any prescription of the 15 antibiotics in the 9 wards where overall antibiotic use had not decreased in the past year.nnnRESULTSnWe analysed 2385 prescriptions, 932 (39%) of which generated an alert for potential intervention. Among the latter, 482 (51.7%) prescriptions prompted direct counselling, mainly for shortening the planned duration of therapy (18.9%), withdrawing antibiotics (16.2%) or streamlining therapy (15.5%). The attending physicians compliance with the recommendations was 80%. The overall median (interquartile range) days of therapy prescribed by the attending physicians was reduced from an initial duration of 8 (7-14) to 7 (6-11) days (P < 0.0001), resulting in 26.5% less antibiotic days prescribed. The time required for the intervention was 6 h per week.nnnCONCLUSIONSnThis computer-prompted post-prescription review led physicians to modify one half of the antibiotic courses initially prescribed and was well accepted by the majority, although they had not requested counselling.

Environmental influences on daily emergency admissions in sickle-cell disease patients.

AbstractPrevious reports have suggested a role for weather conditions and air pollution on the variability of sickle cell disease (SCD) severity, but large-scale comprehensive epidemiological studies are lacking.In order to evaluate the influence of air pollution and climatic factors on emergency hospital admissions (EHA) in SCD patients, we conducted an 8-year observational retrospective study in 22 French university hospitals in Paris conurbation, using distributed lag non-linear models, a methodology able to flexibly describe simultaneously non-linear and delayed associations, with a multivariable approach.During the 2922 days of the study, there were 17,710 EHA, with a mean daily number of 6.1u200a±u200a2.8. Most environmental factors were significantly correlated to each other. The risk of EHA was significantly associated with higher values of nitrogen dioxide, atmospheric particulate matters, and daily mean wind speed; and with lower values of carbon monoxide, ozone, sulfur dioxide, daily temperature (minimal, maximal, mean, and range), day-to-day mean temperature change, daily bright sunshine, and occurrence of storm. There was a lag effect for 12 of 15 environmental factors influencing hospitalization rate. Multivariate analysis identified carbon monoxide, day-to-day temperature change, and mean wind speed, along with calendar factors (weekend, summer season, and year) as independent factors associated with EHA.In conclusion, most weather conditions and air pollutants assessed were correlated to each other and influenced the rate of EHA in SCD patients. In multivariate analysis, lower carbon monoxide concentrations, day-to-day mean temperature drop and higher wind speed were associated with increased risk of EHA.

Low fetal hemoglobin percentage is associated with silent brain lesions in adults with homozygous sickle cell disease

Silent white matter changes (WMCs) on brain imaging are common in individuals with sickle cell disease (SCD) and are associated with cognitive deficits in children. We investigated the factors predictive of WMCs in adults with homozygous SCD and no history of neurological conditions. Patients were recruited from a cohort of adults with homozygous SCD followed up at an adult sickle cell referral center for which steady-state measurements of biological parameters and magnetic resonance imaging scans of the brain were available. WMCs were rated by consensus, on a validated age-related WMC scale. The prevalence of WMCs was 49% (95% confidence interval [CI], 39%-60%) in the 83 patients without vasculopathy included. In univariable analysis, the patients who had WMCs were more likely to be older (P = .003) and to have hypertension (P = .02), a lower mean corpuscular volume (P = .005), a lower corpuscular hemoglobin concentration (P = .008), and a lower fetal hemoglobin percentage (%HbF) (P = .003). In multivariable analysis, only a lower %HbF remained associated with the presence of WMCs (odds ratio [OR] per 1% increase in %HbF, 0.84; 95% CI, 0.72-0.97; P = .021). %HbF was also associated with WMC burden (P for trend = .007). Multivariable ordinal logistic regression showed an inverse relationship between WMC burden (age-related WMC score divided into 4 strata) and HbF level (OR for 1% increase in %HbF, 0.89; 95% CI, 0.79-0.99; P = .039). Our study suggests that HbF may protect against silent WMCs, decreasing the likelihood of WMCs being present and their severity. It may therefore be beneficial to increase HbF levels in patients with WMCs.

Impact d’une prise en charge en centre tertiaire en France sur la mortalité des dermo-hypodermites-fasciites nécrosantes

Introduction nLes dermo-hypodermites-fasciites necrosantes (DHBN-FN) sont des infections rares et graves (25–30xa0% de mortalite). Le delai a la 1re chirurgie est un des facteurs de risque de mortalite. Ce delai depend des delais au diagnostic, a la decision chirurgicale et a l’acces au bloc operatoire. Ces elements pourraient, selon notre hypothese, etre facilites dans les centres de recours tertiaires. L’objectif de cette etude etait d’evaluer l’impact d’une prise en charge ou non en centre tertiaire sur la mortalite des DHBN-FN en France. nMateriel et methodes nLes bases nationales du PMSI ont ete interroges pour la periode 2007–2012xa0afin d’inclure l’ensemble des sejours dont le diagnostic principal comportait le code «xa0fasciite necrosantexa0». Les donnees recueillies retrospectivement etaientxa0: (1) les caracteristiques sociodemographiques et comorbidites, un sejour en reanimation, le transfert interhospitalier et le deces et (2) le type de structure (public/prive) et «xa0l’experiencexa0» dans le domaine (≥3xa0DHBN-FN/an, <xa03). La mortalite etait estimee a court terme (J28) et a moyen terme (derniere date de suivi). Des associations etaient recherchees entre facteurs «xa0hospitaliersxa0» et mortalite apres ajustement sur les caracteristiques despatients. nResultats n1506xa0patients ont ete identifies, âges de 60,3xa0ans (xa0±xa019) (609xa0femmes), pris en charge dans 325xa0centres (82xa0% public, 17xa0% hospitalo-universitaires dont 36xa0% prenant en chargexa0≥xa03xa0DHBN-FN/an). 197 (13xa0%) patients avait ete transferes, 1025 (68xa0%) avaient fait un sejour en reanimation, 271xa0etaient decedes a J28. La figure montre la repartition des structures hospitalieres prenant en charge des DHBN-FN en fonction du nombre de patients et du taux de mortalite. Concernant la mortalite a J28, apres ajustement sur les facteurs de confusion (âge, sexe, comorbidites, sejour en reanimation), les hopitaux universitaires prenant en chargexa0≥xa03xa0DHBN-FN/an etaient associes a une moindre mortalite (ORxa0=xa00,7, IC95xa0% [0,5xa0; 0,9]xa0; pxa0=xa00,04) en comparaison aux hopitaux publics (universitaires ou non) prenant en chargexa0<xa03xa0DHBN-FN/an. Le transfert inter-hospitalier n’etait pas associe a un sur-risque de mortalite (ORxa0=xa00,9 [0,6xa0; 1,4]xa0; pxa0=xa00,73). Les resultats etaient superposables pour la mortalite a moyen terme. nDiscussion nUne moindre mortalite a court et moyen terme des patients DHBN-FN etait observee dans les centres tertiaires prenant en charge plus de 3DHBN-FN/an. De plus, le transfert inter-hospitalier n’etait pas associe a un sur-risque de mortalite, contrairement a certaines etudes anterieures n’ayant pas pris en compte les caracteristiques des structures recevant les patients transferes, et notamment l’experience pour ce type de prise en charge. nConclusion nLes transferts vers les centres tertiaires des DHBN-FN diagnostiquees ou suspectees devraient etre facilites au sein d’une zone geographique definie afin d’esperer une amelioration de la mortalite.

Low Rates of Blood Transfusion in Elective Resections of Neurofibromas in a Cohort Study: Neurofibroma Length as a Predictor of Transfusion Requirement.

Background: Neurofibromas in neurofibromatosis type 1 induce aesthetic and functional morbidity. Perioperative bleeding has been reported as an obstacle to neurofibroma resections. The authors studied the requirement for blood transfusion during surgical treatment of neurofibromatosis type 1. Methods: Six hundred twenty-two procedures performed on 390 neurofibromatosis type 1 patients at the national referral center from 1995 to 2011 were analyzed in two chronologic sets of patients: set 1 (February of 1995 to September of 2007), in which only one surgeon operated; and set 2 (October of 2007 to January of 2011), in which two additional surgeons were involved. Malignant peripheral nerve sheath tumors, reconstructive procedures, and spontaneous hemorrhages were excluded from the analysis. Age, sex, preoperative hemoglobin concentration, location, length, estimated volume and histologic features of the largest neurofibroma (cumulative values for multiple neurofibromas), and procedure duration were studied as potential predictors of blood transfusion that were measured in terms of units of packed red blood cells. Results: Seventy reconstructive procedures, two cases of spontaneous hemorrhage, and 32 malignant peripheral nerve sheath tumor resections were excluded. Among 516 procedures (318 and 198 in sets 1 and 2, respectively), 17 (2.7 percent) required blood transfusions. The requirement for transfusion was associated with neurofibroma length in both sets, with an optimal cutoff value of 13 cm in both sets. Conclusions: Contrary to the literature, the requirement for blood transfusion was found to be low (2.7 percent of the cases) during elective resection of neurofibromas in neurofibromatosis type 1. Elective resections of benign neurofibromas less than 13 cm in length were not associated with a requirement for blood transfusion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.