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Objetivo: O ultrassom pulmonar (USP) à beira do leito é uma técnica de imagem não invasiva e prontamente disponível que pode complementar a avaliação clínica. O protocolo Bedside Lung Ultrasound in Emergency (BLUE, ultrassom pulmonar à beira do leito em situações de emergência) demonstrou elevado rendimento diagnóstico em pacientes com insuficiência respiratória aguda (IRpA). Recentemente, um programa de treinamento em USP à beira do leito foi implementado na nossa UTI. O objetivo deste estudo foi avaliar a acurácia do USP baseado no protocolo BLUE, quando realizado por médicos com habilidades básicas em ultrassonografia, para orientar o diagnóstico de IRpA. Métodos: Ao longo de um ano, todos os pacientes adultos consecutivos respirando espontaneamente admitidos na UTI por IRpA foram prospectivamente inclusos. Após treinamento, 4 operadores com habilidades básicas em ultrassonografia realizaram o USP em até 20 minutos após a admissão na UTI, cegados para a história do paciente. Os diagnósticos do USP foram comparados aos diagnósticos da equipe assistente ao final da internação na UTI (padrão-ouro). Resultados: Foram inclusos na análise 37 pacientes (média etária: 73,2 ± 14,7 anos; APACHE II: 19,2 ± 7,3). O diagnóstico do USP demonstrou concordância com o diagnóstico final em 84% dos casos (kappa total: 0,81). As causas mais comuns de IRpA foram pneumonia (n = 17) e edema pulmonar cardiogênico (n = 15). A sensibilidade e a especificidade do USP comparado ao diagnóstico final foram de 88% e 90% para pneumonia e de 86% e 87% para edema pulmonar cardiogênico, respectivamente. Conclusões: O USP baseado no protocolo BLUE foi reproduzível por médicos com habilidades básicas em ultrassonografia e acurado para o diagnóstico de pneumonia e de edema pulmonar cardiogênico. Objective: Bedside lung ultrasound (LUS) is a noninvasive, readily available imaging modality that can complement clinical evaluation. The Bedside Lung Ultrasound in Emergency (BLUE) protocol has demonstrated a high diagnostic accuracy in patients with acute respiratory failure (ARF). Recently, bedside LUS has been added to the medical training program of our ICU. The aim of this study was to investigate the accuracy of LUS based on the BLUE protocol, when performed by physicians who are not ultrasound experts, to guide the diagnosis of ARF. Methods: Over a one-year period, all spontaneously breathing adult patients consecutively admitted to the ICU for ARF were prospectively included. After training, 4 non-ultrasound experts performed LUS within 20 minutes of patient admission. They were blinded to patient medical history. LUS diagnosis was compared with the final clinical diagnosis made by the ICU team before patients were discharged from the ICU (gold standard). Results: Thirty-seven patients were included in the analysis (mean age, 73.2 ± 14.7 years; APACHE II, 19.2 ± 7.3). LUS diagnosis had a good agreement with the final diagnosis in 84% of patients (overall kappa, 0.81). The most common etiologies for ARF were pneumonia (n = 17) and hemodynamic lung edema (n = 15). The sensitivity and specificity of LUS as measured against the final diagnosis were, respectively, 88% and 90% for pneumonia and 86% and 87% for hemodynamic lung edema. Conclusions: LUS based on the BLUE protocol was reproducible by physicians who are not ultrasound experts and accurate for the diagnosis of pneumonia and hemodynamic lung edema.

International audience; Introduction: Aging is associated with a decline in cardiac contractility and altered immune function. The aim of this study was to determine whether aging alters endotoxin-induced myocardial dysfunction.Methods: Senescent (24 month) and young adult (3 month) male Wistar rats were treated with intravenous lipopolysaccharide (LPS) (0.5 mg/kg (senescent and young rats) or 5 mg/kg (young rats only)), or saline (senescent and young control groups). Twelve hours after injection, cardiac contractility (isolated perfused hearts), myofilament Ca2+ sensitivity (skinned fibers), left ventricular nitric oxide end-oxidation products (NOx and NO2) and markers of oxidative stress (thiobarbituric acid reactive species (TBARS) and antioxidant enzymes) were investigated.Results: LPS (0.5 mg/kg) administration resulted in decreased contractility in senescent rats (left ventricular developed pressure (LVDP), 25 +/- 4 vs 53 +/- 4 mmHg/g heart weight in control; P < 0.05) of amplitude similar to that in young rats with LPS 5 mg/kg (LVDP, 48 +/- 7 vs 100 +/- 7 mmHg/g heart weight in control; P < 0.05). In contrast to young LPS rats (0.5 and 5 mg/kg LPS), myofilament Ca2+ sensitivity was unaltered in senescent LPS hearts. Myocardial NOx and NO2 were increased in a similar fashion by LPS in young (both LPS doses) and senescent rats. TBARS and antioxidant enzyme activities were unaltered by sepsis whatever the age of animals.Conclusion: Low dose of LPS induced a severe myocardial dysfunction in senescent rats. Ca2+ myofilament responsiveness, which is typically reduced in myocardium of young adult septic rats, however, was unaltered in senescent rats. If these results are confirmed in in vivo conditions, they may provide a cellular explanation for the divergent reports on ventricular diastolic function in septic shock. In addition, Ca2+-sensitizing agents may not be as effective in aged subjects as in younger subjects.

Introduction An intensive care information system (ICIS) has numerous advantages. It enables all the patients9 data to be collected in a “computer file”. The automatic acquisition of data reduces human error, and computerised physician order entry limit errors in administering medication. Thanks to computerised data, the creation of a “clinical decision support system” enables diagnosis optimisation and follow-up of treatments. The goal of this study was to evaluate the impact of a personalised ICIS on critically ill patients9 mortality and length of stay in the intensive care unit (ICU). Materials and methods The system chosen for Multidisciplinary ICU (12 beds) of Pitie-Salpetriere hospital in Paris was the program Metavision (IMDsoft, Tel Aviv, Israel). It is an adjustable system, offering the possibility of being completely reformatted and adapted according to specific needs. A team consisting of doctors, nurses, auxiliary nurses, and monitors was trained for 2 weeks to use the program. Then, for 1 month, the ICIS was personalised for the unit before being implemented. After defining the various clinical, biological, and radiological parameters indispensable for diagnosis and follow-up of acute respiratory disease, haemodynamic, renal, and hepatic failures, screens were created, integrating pertinent parameters in the form of tables and graphics. These screens enable all the relevant elements to be grouped together, but also allow the visualisation of their evolution along time. We compared the Simplified Acute Physiology Score (SAPS II) and the Sequential Organ Failure Assessment (SOFA) at patient9s admission, length of patients9 stay in the ICU, and mortality over two 6-month periods: before the implementation of Metavision from June to November 2008, and after implementation, from March to August 2009. Data were compared between groups by a Mann–Whitney test (median and IQR 25–75%), and a χ 2 test. The first 3 months following the implementation of Metavision were not taken into account, in order to exclude the difficulties inherent to the implementation of a new computerised system. Results One hundred twelve patients were hospitalised between June and November 2008, and 160 between March and November 2009. SAPS II and SOFA scores showed no difference between the two groups: (SAPS II: 39 (26–54) vs 44 (28–59), p=0.7, SOFA: 6 (3–10) vs 6 (4–10), p=0.49). The length of stay in intensive care was shortened by 2 days after implementation of Metavision: 9 (5–20) versus 7 (3.5–14), p=0.02. A trend was observer towards a decrease in mortality: 17% to 14.5%, p=0.6. Discussion The interest of the system we have chosen is its adjustability, its ability to combine on the same screen (“clinical decision support screen”), a high number of clinical, biological, or radiological data. These screens enable the assessment of therapies on patients9 organ failures. ICIS enables optimisation of patient9s care, which may explain the reduction in duration of patients9 stay in the ICU. It overcomes the usual limits of ICIS consist of an imperfect adaptation to specific medical needs. Conclusion A specifically-designed intensive care information system enables improvement of patient care, and reduction of the length of stay in the ICU. It requires a substantial investment from physician regarding learning programs and creating personalised tools for diagnosis and follow up assistance. It also requires a close collaboration between physicians and computer scientists. Introduction L9informatisation d9un service de reanimation a de nombreux avantages. Elle permet de rassembler dans le « dossier informatique », toutes les donnees des patients. L9acquisition automatique des donnees diminue l9erreur humaine, et les logiciels de prescriptions limitent les erreurs d9administration de medicament. Grâce aux donnees informatisees, la creation d9un « Systeme d9aide aux decisions medicales » permet d9optimiser le diagnostic et le suivi des therapeutiques. Le but de cette etude etait d9evaluer l9impact de l9informatisation personnalisee du service sur la mortalite et la duree de sejour en reanimation. Materiel et methode Le systeme choisit pour informatiser le service de Reanimation Polyvalente (12 lits) est le logiciel Metavision (IMDsoft, Tel Aviv, Israel). Ce systeme est modulable. Il est livre avec la possibilite d9etre completement remis en forme et adapte en fonction des besoins du service. Une equipe composee de medecins, infirmiers, aides-soigants et surveillants a ete formee au logiciel pendant deux semaines. Puis pendant un mois le dossier a ete personnalise pour le service avant d9etre implante. L9accent a ete mis sur la creation d9 « ecrans d9aide au diagnostic ». Apres avoir defini les differents parametres cliniques, biologiques et radiologiques indispensables au diagnostic et a la prise en charge d9une pneumopathie, d9une defaillance hemodynamique, renale et hepatique, des ecrans ont ete crees en integrant ces parametres sous formes de tableau et de graphique. Ces ecrans permettent de regrouper tous les elements pertinents mais aussi de visualiser leur evolution dans le temps. Nous avons compare les scores d9Indice de Gravite Simplifie (IGS) et de defaillance d9organe (SOFA) a l9admission, la duree de sejour et la mortalite sur deux periodes de six mois: avant l9implantation du logiciel de juin a novembre 2008 et apres l9implantation de Mars a Aout 2009. Les deux groupes de patients ont ete analyses par un test de Mann-Whitney (mediane et 25–75% Interquartile) et un test de Chi-2. Les trois premiers mois suivant la mise en place du systeme n9ont pas ete pris en compte pour exclure les difficultes inherentes a la mise en place d9un nouveau systeme. Resultats Cent douze patients ont ete hospitalises entre juin et novembre 2008 et 160 entre mars et novembre 2009. Les scores d9IGS et de SOFA n9etaient pas differents entre les 2 groupes: [IGS: 39 (26–54) vs 44 (28–59), p=0.7; SOFA: 6 (3–10) vs 6 (4–10), p=0.49]. La duree d9hospitalisation en reanimation a ete raccourcie de 2 jours apres l9implantation du logiciel: 9 (5–20) vs 7 (3.5–14), p=0.02. La mortalite est passee de 17% a 14.5%, p=0.6. Discussion L9interet du systeme que nous avons choisi est sa plasticite, sa capacite a regrouper sur un meme ecran d9aide au diagnostic un nombre d9informations tres variables qu9elles soient cliniques, biologiques ou radiologiques. Ces ecrans permettent precisement d9evaluer et de suivre l9evolution des defaillances d9organes des patients. L9informatisation permet d9optimiser la prise en charge du patient ce qui pourrait expliquer la diminution de duree sejour en reanimation. Les limites des systemes informatiques sont qu9ils ne sont pas crees par les medecins et donc parfois imparfaitement adaptes aux besoins medicaux. Conclusion L9informatisation personnalisee d9un service permet d9ameliorer la prise en charge des patients et de raccourcir la duree de sejour en reanimation. Elle necessite un investissement important de la part des medecins en terme d9apprentissage du logiciel et de la creation d9outils personnalises d9aide au diagnostic. Elle requiert aussi une collaboration etroite entre medecins et informaticiens du systeme adopte et de l9hopital.

In humans, several grams of IgA are secreted every day in the intestinal lumen. While only one IgA isotype exists in mice, humans secrete IgA1 and IgA2, whose respective relations with the microbiota remain elusive. We compared the binding patterns of both polyclonal IgA subclasses to commensals and glycan arrays and determined the reactivity profile of native human monoclonal IgA antibodies. While most commensals are dually targeted by IgA1 and IgA2 in the small intestine, IgA1+IgA2+ and IgA1-IgA2+ bacteria coexist in the colon lumen, where Bacteroidetes is preferentially targeted by IgA2. We also observed that galactose-α terminated glycans are almost exclusively recognized by IgA2. Although bearing signs of affinity maturation, gut-derived IgA monoclonal antibodies are cross-reactive in the sense that they bind to multiple bacterial targets. Private anticarbohydrate-binding patterns, observed at clonal level as well, could explain these apparently opposing features of IgA, being at the same time cross-reactive and selective in its interactions with the microbiota.