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The members of the Palurea Study Group were provided in such a way that they could not be indexed as collaborators on PubMed. The publisher apologizes for this error and is pleased to list the members of the group here.

Purpose: Prospective data on potential factors associated with severity of imported Plasmodium falciparum malaria are lacking. We evaluated whether several host- and parasite-related biomarkers may improve early severity evaluation., Methods: Prospective multicenter observational study comparing uncomplicated and severe imported falciparum malaria in adults conducted in France in 52 units, from 2007 to 2010. Association of several host- and parasite-related biomarkers with severity of malaria was tested using univariate and multivariate analyses., Results: Of 295 patients, 140 had uncomplicated malaria and 155 severe malaria (including very severe and less severe cases according to predefined criteria). Curative intravenous quinine treatment was used in 154/155 patients with severe malaria and atovaquone/proguanil in 74 % of patients with uncomplicated malaria. Hospital mortality was 5.2 % (8 patients), all in the severe malaria group. Among host-related biomarkers, CRP, procalcitonin, and sTREM-1 were significantly higher and albumin was significantly lower in severe versus uncomplicated malaria; only the last three biomarkers also differed significantly between the very and less severe malaria groups. Among parasite-related biomarkers, only plasma PfHRP2 was significantly higher in severe versus uncomplicated malaria and in very severe versus less severe malaria; parasitemia did not differ between very and less severe malaria. By multivariate analysis, only lower plasma albumin and higher sTREM-1 were associated with greater severity, with intermediate accuracies., Conclusions: During imported malaria, the most useful biomarkers associated with severity seem to be plasma albumin and sTREM-1; and among parasite-related parameters, PfHRP2 was more strongly associated with severity than parasitemia was.

Purpose: CD64 expression on the surface of neutrophils has recently been proposed as an early marker of bacterial infection. The goal of this study was to determine whether the CD64 index allows differentiation of bacterial sepsis from viral and fungal sepsis and other inflammatory states in a critical-care setting., Methods: This was an observational prospective study conducted in a medical ICU of a university hospital. All patients admitted between September 2009 and March 2010 with at least two criteria for systemic inflammatory response syndrome (SIRS) were eligible for inclusion. Upon admission, hematological exams were conducted by flow cytometry, allowing quantification of CD64 expression (Leuko64™ kit, Trillium Diagnostics LLC, USA). ROC curve analysis was performed to evaluate the utility of the CD64 index in the diagnosis of bacterial infection. Patients with suspected infection were excluded when infection could not be microbiologically confirmed., Results: Our study included 293 patients with a SAPS II score of 45 (31-59). Bacterial infection was found in 148 patients and SIRS or non-bacterial infection was documented in 145 patients. A CD64 index greater than 2.2 predicted bacterial infection with a sensitivity and specificity of 63% (55-71%) and 89% (83-94%), respectively. The area under the ROC curve was 0.8 (0.75-0.84). Positive and negative likelihood ratios were 5.7 (5.0-6.5) and 0.4 (0.3-0.7), respectively., Conclusions: The CD64 index is specific for bacterial infection among ICU patients. As a result of its weak sensitivity, the CD64 index may not be practically recommended, but it may be useful in combination with a more sensitive biological marker.

Objective: To assess the usefulness of dialysis with the molecular adsorbent recirculating system (MARS) in patients with acute liver failure who fulfil criteria for liver transplantation., Design: Observational cohort study., Setting: ICU at a liver transplantation centre., Patients: Twenty-two patients (23 episodes) received MARS dialysis. They were either listed for LT (n=14), delayed (n=1), or not listed (contra-indication, n=7)., Interventions: A total of 56 MARS treatments (median per patient 2; mean duration 7.6+/-2.6h) were performed on haemodialysis., Measurements and Results: Clinical and biological variables were assessed before and 24[Symbol: see text]h after MARS therapy. The rate of recovery of liver function without transplantation was compared with an expected rate and survival was analysed. Following MARS dialysis, we observed an improvement in the grade of hepatic encephalopathy (P=0.02) and the Glasgow coma score (P=0.02), a decrease in conjugated bilirubin (P=0.05) and INR (P=0.006), and an increase in prothrombin index (P=0.005). Overall, liver function improved in seven patients (32%): four listed patients in whom transplantation could be avoided and three patients among those not listed due to contra-indications. The transplant-free recovery rate in listed patients was 29% (vs. expected 9%, P=0.036). Listed patients (n=14) had a higher 30-day survival rate [86% (12/14) vs 38% (3/8), P=0.05] and a higher long-term survival rate (P=0.02)., Conclusions: A statistically significant improvement of liver function was observed after MARS therapy. Transplant-free recovery was more frequent than expected. The apparent benefit of MARS dialysis to treat acute liver failure needs to be confirmed by a controlled study.

Objective: This prospective observational study was undertaken in order to assess pain experienced by intensive care unit patients at the time of extubation and to identify factors associated with pain of at least moderate intensity., Design: Prospective observational study., Setting: Intensive care unit at a university hospital., Patients: During a 1-year period the presence, severity and clinical predictors of orofacial and/or chest pain among patients undergoing removal of endotracheal tubes was assessed., Measurements and Results: Pain was evaluated using a visual analogue scale (VAS). Of 332 extubated patients, 203 could be evaluated. During the peri-extubation period, pain was significantly associated with a SAPS II score more than 36 ( p=0.03) and duration of mechanical ventilation (MV) of 6 days or more ( p=0.002), whereas intubation in the operating room was associated with less pain ( p=0.001). Pain of at least moderate intensity (VAS score >30 mm) was reported by 73% of patients and pain of severe intensity (VAS score >50 mm) was reported by 45% of patients. MV duration of 6 days or more was the only independent risk factor for pain of at least moderate intensity (OR 2.4, 95% CI 1.03-5.4, p=0.04). We also observed that pain had resolved 1 h after extubation in the majority of patients., Conclusion: Our results suggest that, in intensive care unit patients, peri-extubation pain is frequent and should be considered for treatment, especially in patients with longer intubation.

Objective: To recognize patients with unresponsive septic shock and right ventricular (RV) failure and to evaluate the effects of epinephrine on RV performance in these patients., Design: Prospective descriptive study., Setting: Medical intensive care unit., Subjects: 14 consecutive patients in septic shock unresponsive to fluid loading, dopamine, and dobutamine., Interventions: Evaluation of RV function by thermodilution with a pulmonary artery catheter equipped with a rapid-response thermistor. Measurements were obtained before and during epinephrine infusion to achieve a systolic arterial pressure > or = 90 mmHg or a mean arterial pressure (MAP) > or = 70 mmHg., Results: At the time of inclusion in the study the hemodynamic pattern in the 14 patients was as follows: (MAP) 58 +/- 14 mmHg, systemic vascular resistance (SVR) 1046 +/- 437 dyne.s.cm-5.m-2, pulmonary artery occlusion pressure (PAOP) 14 +/- 4 mmHg, mean pulmonary artery pressure (MPAP) 24 +/- 4 mmHg, right arterial pressure (RAP) 11 +/- 4 mmHg, cardiac index (CI) 4 +/- 1.7 l/min per m2. During epinephrine infusion, MAP, CI and stroke volume index (SVI) were increased (27%, p < 0.01; 20%, p < 0.01; 15%, p < 0.05, respectively). There was no change in PAOP, SVR or heart rate. Seven patients (group A) had marked RV failure defined by both RV dilation [RV end-diastolic volume index (RVEDVI) > 92 ml/m2] and low RV ejection factor (RVEF) (< 52%) and 7 did not (group B). Group A had a lower baseline RVEF than group B (24 +/- 7 vs 45 +/- 9%, p < 0.05), a higher RVEDVI (134 +/- 28 vs 79 +/- 17 ml/ m2, p < 0.01), and a higher RVES (systolic) VI (103 +/- 30 vs 43 +/- 11 ml/ m2, p < 0.01). The other hemodynamics, especially RAP and RV stroke work index (RVSWI) were no different in the two groups and did not predict RV dysfunction. In group A, epinephrine infusion improved RVEF (25%, p < 0.05) by a reduction in RVESVI (-8%, p < 0.05) without any change in RVEDVI or in RAP, in spite of a rise in MPAP (11%, p < 0.05). A rise in RVSWI (76%, p < 0.05), SVI (23%, p < 0.05), and CI (24%, p < 0.05) was also achieved. An upward vertical shift of the Frank-Starling relationship RVSWI/ RVEDVI and an upward shift to the left of the pressure volume relationship pulmonary artery peak pressure/RVESVI was observed only in the group with RV failure following treatment with epinephrine. In group B (without RV failure), RV parameters were not modified by epinephrine., Conclusion: In patients with severe septic shock, RV dysfunction was identified by the use of an RVEF pulmonary artery catheter and was improved by epinephrine by means of an improvement in RV contractility.