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Purpose Our aim was to assess the diagnostic performance in determining strangulation in small bowel obstruction (SBO) for five CT findings commonly considered in published small bowel obstruction (SBO) management guidelines. Materials and methods Medical databases were searched for “bowel obstruction”, “computed tomography”, “strangulation”, and related terms. Two reviewers independently selected articles for CT findings investigated with surgical or histological reference standards for strangulation. Bivariate random-effects meta-analytical methods were used. Results A total of 768 patients, including 205 with strangulation from nine studies, were evaluated. The reduced bowel wall enhancement CT sign had the highest specificity (95 %, CI 75–99), with a positive LR of 11.07 (2.27–53.88) and DOR of 22.86 (4.99–104.61). The mesenteric fluid sign had the highest sensitivity (89 %, CI 75–96) with a negative LR of 0.16 (0.07–0.39) and a DOR of 13.9 (5.73–33.75). The bowel wall thickness had a sensitivity of 48 % (CI 41–54), a specificity of 83 % (CI 74–89), a positive LR of 2.84 (1.83–4.41) and a negative LR of 0.62 (0.53–0.72). The other CT findings had lower diagnostic performance. Conclusion Two CT findings should be used in clinical practice: reduced enhanced bowel wall is highly predictive of ischemia, and absence of mesenteric fluid is a reliable finding to rule out strangulation. Key Points • Reduced bowel wall enhancement on CT increases the probability of strangulation 11 - fold . • Absence of mesenteric fluid on CT decreases the probability of strangulation 6-fold . • The clinical reliability of other CT signs is doubtful for predicting strangulation .

BackgroundChronic subdural hematoma (CSDH) is a common condition requiring surgical treatment; however, recurrence occurs in 15% of cases at 1 year. Middle meningeal artery (MMA) embolization has recently emerged as a promising treatment to prevent CSDH recurrence.ObjectiveTo investigate the effect of MMA embolization on hematoma volume resorption (HVR) after surgery in symptomatic patients.MethodsFrom April 2018 to October 2018, participants with CSDH requiring surgery were prospectively randomized in a pilot study, and received either surgical treatment alone (ST group) or surgery and adjuvant MMA embolization (ST+MMAE group). The primary outcome was HVR measured on the 3 month CT scan compared with the immediate pre-embolization CT scan. Secondary outcomes were clinical recurrence of CSDH and safety measures.Results46 patients were randomized and 41 of these achieved a 3 month follow-up . Twenty-one patients received MMA embolization. At 3 months, the HVR from postsurgical level was higher in the ST+MMAE group (mean difference 17.5 mL, 95% CI 3.87 to 31.16 mL; p=0.015). Two participants presented a CSDH recurrence (one in each group). One patient died (ST group). No MMA embolization-related adverse events were reported.ConclusionThe addition of MMA embolization to surgery led to an increase in CSDH resorption at 3 months. One recurrence of CSDH was reported in each group, and there were no treatment-related complications.

Abstract Rationale The diagnostic concordance between transbronchial lung cryobiopsy (TBLC)—versus surgical lung biopsy (SLB) as the current gold standard—in interstitial lung disease (ILD) cases requiring histology remains controversial. Objectives To assess diagnostic concordance between TBLC and SLB sequentially performed in the same patients, the diagnostic yield of both techniques, and subsequent changes in multidisciplinary assessment (MDA) decisions. Methods A two-center prospective study included patients with ILD with a nondefinite usual interstitial pneumonia pattern (on high-resolution computed tomography scan) confirmed at a first MDA. Patients underwent TBLC immediately followed by video-assisted thoracoscopy for SLB at the same anatomical locations. After open reading of both sample types by local pathologists and final diagnosis at a second MDA (MDA2), anonymized TBLC and SLB slides were blindly assessed by an external expert pathologist (T.V.C.). Kappa-concordance coefficients and percentage agreement were computed for: TBLC versus SLB, MDA2 versus TBLC, MDA2 versus SLB, and blinded pathology versus routine pathology. Measurements and Main Results Twenty-one patients were included. The median TBLC biopsy size (longest axis) was 7 mm (interquartile range, 5–8 mm). SLB biopsy sizes averaged 46.1 ± 13.8 mm. Concordance coefficients and percentage agreement were: TBLC versus SLB: κ = 0.22 (95% confidence interval [CI], 0.01–0.44), percentage agreement = 38% (95% CI, 18–62%); MDA2 versus TBLC: κ = 0.31 (95% CI, 0.06–0.56), percentage agreement = 48% (95% CI, 26–70)%; MDA2 versus SLB: κ = 0.51 (95% CI, 0.27–0.75), percentage agreement = 62% (95% CI, 38–82%); two pneumothoraces (9.5%) were recorded during TBLC. TBLC would have led to a different treatment if SLB was not performed in 11 of 21 (52%) of cases. Conclusions Pathological results from TBLC and SLB were poorly concordant in the assessment of ILD. SLBs were more frequently concordant with the final diagnosis retained at MDA.

Abstract Rationale Diaphragmatic insults occurring during intensive care unit (ICU) stays have become the focus of intense research. However, diaphragmatic abnormalities at the initial phase of critical illness remain poorly documented in humans. Objectives To determine the incidence, risk factors, and prognostic impact of diaphragmatic impairment on ICU admission. Methods Prospective, 6-month, observational cohort study in two ICUs. Mechanically ventilated patients were studied within 24 hours after intubation (Day 1) and 48 hours later (Day 3). Seventeen anesthetized intubated control anesthesia patients were also studied. The diaphragm was assessed by twitch tracheal pressure in response to bilateral anterior magnetic phrenic nerve stimulation (Ptr,stim). Measurements and Main Results Eighty-five consecutive patients aged 62 (54–75) (median [interquartile range]) were evaluated (medical admission, 79%; Simplified Acute Physiology Score II, 54 [44–68]). On Day 1, Ptr,stim was 8.2 (5.9–12.3) cm H2O and 64% of patients had Ptr,stim less than 11 cm H2O. Independent predictors of low Ptr,stim were sepsis (linear regression coefficient, −3.74; standard error, 1.16; P = 0.002) and Simplified Acute Physiology Score II (linear regression coefficient, −0.07; standard error, 1.69; P = 0.03). Compared with nonsurvivors, ICU survivors had higher Ptr,stim (9.7 [6.3–13.8] vs. 7.3 [5.5–9.7] cm H2O; P = 0.004). This was also true for hospital survivors versus nonsurvivors (9.7 [6.3–13.5] vs. 7.8 [5.5–10.1] cm H2O; P = 0.004). Day 1 and Day 3 Ptr,stim were similar. Conclusions A reduced capacity of the diaphragm to produce inspiratory pressure (diaphragm dysfunction) is frequent on ICU admission. It is associated with sepsis and disease severity, suggesting that it may represent another form of organ failure. It is associated with a poor prognosis. Clinical trial registered with www.clinicaltrials.gov (NCT 00786526).

Purpose Although rapid response systems are known to reduce in-hospital cardiac arrest rate, their effect on mortality remains debated. The present study aimed to evaluate the effect of implementing an intensivist-led rapid response team (RRT) on mortality in hospitalized patients. Methods An implementation of an intervention and a comparison with retrospective data analysis were performed in the four hospitals of Montpellier regional healthcare centre, in France. An intensivist-led RRT was implemented on a 24/7 basis along with educational modules, publicity and bedside simulation-based training in only one of the four hospitals from January 2012 to June 2012. A single activation criterion (heart rate below 40/min or above 140/min, systolic blood pressure below 80 mmHg, cardiac arrest, respiratory rate below 8/min or above 30/min, pulse oximetry below 90 % with O 2 above 6 l/min, respiratory distress in a tracheotomised patient, respiratory arrest, coma or sudden change in level of consciousness, seizure) allowed any caregiver to directly contact the RRT using a dedicated cell phone number. Patients over 18 years admitted for more than 24 h in the medical-surgical wards from July 2010 to December 2011 (pre-RRT period) and from July 2012 to December 2013 (RRT period) were included. The main outcome was unexpected mortality. Analyses of data from one RRT hospital and three control hospitals (no RRT hospital) were performed. Results RRT implementation was associated with a decrease in unexpected mortality rate in the hospital that implemented RRT (from 21.9 to 17.4 per 1000 discharges; p  = 0.002). Reduction in unexpected mortality associated with RRT implementation could be estimated at 1.5 lives saved per week in the RRT hospital. In the three other hospitals, mortality rate was not significantly modified (from 19.5 to 19.9 per 1000 discharges; p  = 0.69). Overall mortality decreased from 39.6 to 34.6 per 1000 discharges between the pre-RRT and RRT period in the RRT hospital ( p  = 0.012), but did not significantly change in the other hospitals. Patients in the RRT hospital were more frequently admitted to the intensive care unit (ICU) during the RRT period (45.8 vs 52.9 per 1000; p  = 0.002), and their sequential organ failure assessment (SOFA) score upon ICU admission significantly decreased from 7 (4–10) to 5 (2–9); p  < 0.001. Conclusions In the present retrospective study, implementation of an intensivist-led RRT along with educational modules, publicity and bedside simulation-based training was associated with a significant decrease in unexpected and overall mortality of inpatients.

Purpose To assess the impact of different electronic relaxation devices on common stressful patient symptoms experienced in intensive care unit (ICU). Methods Sixty critically ill patients were enrolled in four relaxation sessions using a randomized cross-over design: standard relaxation (TV/radio), music therapy (MUSIC-CARE©), and two virtual reality systems using either real motion pictures (DEEPSEN©) or synthetic motion pictures (HEALTHY-MIND©). The goal was to determine which device was the best to reduce overall patient discomfort intensity (0–10 Numeric Rating Scale (NRS); primary endpoint). Secondary endpoints were specific stressful symptoms (pain, anxiety, dyspnea, thirst, and lack of rest feeling) and stress response measured by Analgesia/Nociception Index (ANI). Multivariate mixed-effect analysis was used, taking into account patient characteristics and multiple measurements. Results Fifty patients followed the full research protocol, and ten patients did at least one research planned session of relaxation. HEALTHY-MIND© was associated with a significant decrease in overall discomfort, the primary endpoint (median NRS = 4[2–6] vs. 2[0–5]; p  = 0.01, mixed-effect model), accompanied by a significant decrease in stress response (increase in ANI, secondary endpoint; p  < 0.01). Regarding other secondary endpoints, each of the two virtual reality systems was associated with a decrease in anxiety ( p  < 0.01), while HEALTHY-MIND© was associated also with a decrease in pain ( p  = 0.001) and DEEPSEN© with a decrease in lack of rest ( p  = 0.01). Three incidents (claustrophobia/dyspnea/agitation) were reported among 109 virtual reality sessions. Cybersickness was rare (NRS = 0[0–0]). Conclusion Electronic relaxation therapy is a promising, safe, and effective non-pharmacological solution that can be used to improve overall discomfort in alert and non-delirious ICU patients. Its effectiveness depends on technical characteristics (virtual reality using a synthetic imagined world versus a real world or music therapy alone without virtual reality), as well as the type of symptoms. Key messages Electronic relaxation therapies are effective supportive care tools for improving stressful symptoms in ICU patients. Effectiveness depends on the type of symptom and the characteristics of the devices. Overall discomfort and adrenergic stress response are more significantly improved by virtual reality using a synthetic imagined world than using a real world or music therapy alone.

PurposeThe relation between driving pressure (plateau pressure-positive end-expiratory pressure) and mortality has never been studied in obese ARDS patients. The main objective of this study was to evaluate the relationship between 90-day mortality and driving pressure in an ARDS population ventilated in the intensive care unit (ICU) according to obesity status.MethodsWe conducted a retrospective single-center study of prospectively collected data of all ARDS patients admitted consecutively to a mixed medical-surgical adult ICU from January 2009 to May 2017. Plateau pressure, compliance of the respiratory system (Crs) and driving pressure of the respiratory system within 24 h of ARDS diagnosis were compared between survivors and non-survivors at day 90 and between obese (body mass index ≥ 30 kg/m2) and non-obese patients. Cox proportional hazard modeling was used for mortality at day 90.ResultsThree hundred sixty-two ARDS patients were included, 262 (72%) non-obese and 100 (28%) obese patients. Mortality rate at day 90 was respectively 47% (95% CI, 40–53) in the non-obese and 46% (95% CI, 36–56) in the obese patients. Driving pressure at day 1 in the non-obese patients was significantly lower in survivors at day 90 (11.9 ± 4.2 cmH2O) than in non-survivors (15.2 ± 5.2 cmH2O, p < 0.001). Contrarily, in obese patients, driving pressure at day 1 was not significantly different between survivors (13.7 ± 4.5 cmH2O) and non-survivors (13.2 ± 5.1 cmH2O, p = 0.41) at day 90. After three multivariate Cox analyses, plateau pressure [HR = 1.04 (95% CI 1.01–1.07) for each point of increase], Crs [HR = 0.97 (95% CI 0.96–0.99) for each point of increase] and driving pressure [HR = 1.07 (95% CI 1.04–1.10) for each point of increase], respectively, were independently associated with 90-day mortality in non-obese patients, but not in obese patients.ConclusionsContrary to non-obese ARDS patients, driving pressure was not associated with mortality in obese ARDS patients.

IntroductionWhen both severe metabolic acidemia (pH equal or less than 7.20; PaCO2 equal or less than 45 mm Hg and bicarbonate concentration equal or less than of 20 mmol/L) and moderate-to-severe acute kidney injury are observed, day 28 mortality is approximately 55%–60%. A multiple centre randomised clinical trial (BICARICU-1) has suggested that sodium bicarbonate infusion titrated to maintain the pH equal or more than 7.30 is associated with a higher survival rate (secondary endpoint) in a prespecified stratum of patients with both severe metabolic acidemia and acute kidney injury patients. Whether sodium bicarbonate infusion may improve survival at day 90 (primary outcome) in these severe acute kidney injury patients is currently unknown.Methods and analysisThe sodium bicarbonate for the treatment of severe metabolic acidosis with moderate or severe acute kidney injury in the critically ill: a randomised clinical trial (BICARICU-2) trial is an investigator-initiated, multiple centre, stratified, parallel-group, unblinded trial with a computer-generated allocation sequence and an electronic system-based randomisation. After randomisation, the intervention group will receive 4.2% sodium bicarbonate infusion to target a plasma pH equal or more than 7.30 while the control group will not receive sodium bicarbonate. The primary outcome is the day 90 mortality. Main secondary outcomes are organ support dependences.Ethics and disseminationThe trial has been approved by the appropriate ethics committee (CPP Nord Ouest, Rouen, France, 25 April 2019, number: 19.03.15.72446). Informed consent is required. If sodium bicarbonate improves day 90 mortality, it will become part of the routine care.Trial registration numberNCT04010630.

Background Intensive care unit (ICU)-acquired weakness (ICU-AW) and ICU-acquired diaphragm dysfunction (ICU-DD) occur frequently in mechanically ventilated (MV) patients. It is unknown whether they have different risk factors and different impacts on outcome. This study was designed to (1) describe the respective risk factors associated with ICU-AW and severe ICU-DD and (2) evaluate the respective impact of ICU-AW and severe ICU-DD on outcome. Methods Post hoc analysis of two prospective cohort studies conducted in two ICUs. In patients mechanically ventilated for at least 24 h undergoing a first spontaneous breathing trial, severe ICU-DD was defined as diaphragm twitch pressure < 7 cmH 2 O and ICU-AW was defined as Medical Research Council Score < 48. Results One hundred sixteen patients were assessed. Factors independently associated with severe ICU-DD were age, longer duration of MV, and exposure to sufentanil, and those factors associated with ICU-AW were longer duration of MV and exposure to norepinephrine. Severe ICU-DD (OR 3.56, p  = 0.008), but not ICU-AW, was independently associated with weaning failure (59%). ICU-AW (OR 4.30, p  = 0.033), but not severe ICU-DD, was associated with ICU mortality. Weaning failure and mortality rate were higher in patients with both severe ICU-DD and ICU-AW (86% and 39%, respectively) than in patients with either severe ICU-DD (64% and 0%) or ICU-AW (63% and 13%). Conclusion Severe ICU-DD and ICU-AW have different risk factors and different impacts on weaning failure and mortality. The impact of the combination of ICU-DD and ICU-AW is more pronounced than their individual impact.

The majority of caries lesions in adults occur on the proximal tooth surfaces of the posterior teeth. A comprehensive study of the composition of the oral microbiota is fundamental for a better understanding of the etiology of interdental caries. Twenty-five caries-free subjects (20-35 years old) were enrolled in the study. The interdental biofilm of four interdental sites were collected. The real-time polymerase chain reaction (PCR) methodology were used to quantify (i) the following bacteria: Streptococcus spp., Streptococcus mutans, Lactobacillus spp., Enterococcus spp., and Enterococcus faecalis; (ii) the fungus Candida albicans; and (iii) total bacteria. Streptococcus spp. was the most abundant species, followed by Lactobacillus spp. and Enterococcus spp. Streptococcus spp. and Lactobacillus spp. were detected at all tested sites and Enterococcus spp. at 99% of sites. S. mutans was detected at only 28% of the tested sites and C. albicans was detected at 11% of sites. E. faecalis was never detected. In 54.5% of the biofilm inhabited by C. albicans, S. mutans was present. Moreover, 28% of the ID sites co-expressed S. mutans and Lactobacillus spp. The studied pathogens were organized into two correlated groups of species. Strikingly, the fungus C. albicans and the bacteria Enterococcus spp. cluster together, whereas Streptococcus spp., S. mutans and Lactobacillus spp. form one distinct cluster. The interdental biofilm of young caries-free adults is comprised of pathogens that are able to induce interproximal caries. That several of these pathogens are implicated in heart disease or other systemic diseases is an argument for the disruption of interdental biofilms using daily oral hygiene.