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Purpose To assess the feasibility and validity of ultrasonographic measurement of gastric antral cross-sectional area (usCSA) in critically ill patients to predict gastric volume and the use of computed tomography (CT) as a reference to measure gastric volume. Method This single-center, prospective, cross-sectional study included 55 critically ill patients who had an abdominal CT scan. usCSA measurements were performed within the hour preceding the CT scan. Gastric volumes were measured on the CT scan using semiautomatic software. The feasibility rate, performing conditions (% 'good' and 'poor'), internal and external validity of antral usCSA measurements, performed by an ICU physician, were assessed to predict gastric volume. Results Antral usCSA measurements were feasible in 95 % of cases and were positively correlated with gastric volume measured by the CT scan when performed in 'good' conditions (65 %) (r = 0.43). There was good reproducibility of measurements (intraclass correlation coefficient of 0.97, CI 95 % 0.96-0.99) and there was clinically acceptable agreement between measurements performed by radiologists and intensivists (bias -0.12 cm.sup.2). The receiver operating characteristic curve identified a cutoff value of 3.6 cm.sup.2 that discriminated an 'at-risk stomach' (volume >0.8 mL/kg) at a sensitivity of 76 % and a specificity of 78 %. Conclusions Ultrasonographic measurement of antral CSA is feasible and reliable in the majority of critically ill patients. This technique could be useful to manage critically ill patients at risk of aspiration or with enteral feeding., Author(s): S. R. Hamada [sup.1] [sup.2] [sup.3] [sup.4], P. Garcon [sup.5] [sup.6] [sup.7] [sup.8], M. Ronot [sup.2] [sup.9] [sup.10], S. Kerever [sup.11] [sup.12], C. Paugam-Burtz [sup.1] [sup.2] [sup.9], J. Mantz [...]

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Non-alcoholic steatohepatitis (NASH) is characterized at histology by steatosis, hepatocyte ballooning and inflammatory infiltrates, with or without fibrosis. Although diamagnetic material in fibrosis and inflammation can be detected with quantitative susceptibility imaging, fatty acid composition changes in NASH relative to simple steatosis have also been reported. Therefore, our aim was to develop a single magnetic resonance (MR) acquisition and post-processing scheme for the diagnosis of steatohepatitis by the simultaneous quantification of hepatic fat content, fatty acid composition, T2* transverse relaxation time and magnetic susceptibility in patients with non-alcoholic fatty liver disease. MR acquisition was performed at 3.0 T using a three-dimensional, multi-echo, spoiled gradient echo sequence. Phase images were unwrapped to compute the B0 field inhomogeneity (Δ B0) map. The Δ B0-demodulated real part images were used for fat-water separation, T2* and fatty acid composition quantification. The external and internal fields were separated with the projection onto dipole field method. Susceptibility maps were obtained after dipole inversion from the internal field map with single-orientation Bayesian regularization including spatial priors. Method validation was performed in 32 patients with biopsy-proven, non-alcoholic fatty liver disease from which 12 had simple steatosis and 20 NASH. Liver fat fraction and T2* did not change significantly between patients with simple steatosis and NASH. In contrast, the saturated fatty acid fraction increased in patients with NASH relative to patients with simple steatosis (48 ± 2% versus 44 ± 4%; p < 0.05) and the magnetic susceptibility decreased (−0.30 ± 0.27 ppm versus 0.10 ± 0.14 ppm; p < 0.001). The area under the receiver operating characteristic curve for magnetic susceptibility as NASH marker was 0.91 (95% CI: 0.79-1.0). Simultaneous MR quantification of fat content, fatty acid composition, T2* and magnetic susceptibility is feasible in the liver. Our preliminary results suggest that quantitative susceptibility imaging has a high diagnostic performance for the diagnosis of NASH. [ABSTRACT FROM AUTHOR]

A central element was first described in focal nodular hyperplasia (FNH) as a so-called 'central scar,' and is normally associated with this entity. However, many other liver masses may present with a central element. Depending on its appearance, and the lesion itself, central elements can be essential, helpful, or confusing for diagnosis. Indeed, nodules that develop on liver vascular disorders, fibrolamellar hepatocellular carcinoma, large hemangioma, peripheral cholangiocarcinoma, or epithelioid hemangioenthelioma often present with a central element, thus increasing the level of diagnostic confidence when present. On the other hand, central elements are rare or atypical in liver metastases, hepatocellular adenoma, or hepatocellular carcinoma. In this setting, the presence of a central element can lead to a misdiagnosis. The description and details of the imaging features of these different central elements, especially on MRI, as well as a thorough evaluation of the entire lesion, can improve the diagnostic performance in these cases. [ABSTRACT FROM AUTHOR]

Background: Arterial and central venous femoral catheters (fAC-CVC) use during the initial management of severe trauma patients is not a standard technique in most trauma centers. Arguments in favor of their use are: continuous monitoring of blood pressure, safe drug administration, easy blood sampling and potentially large bore venous access. The lack of evidence makes the practice heterogeneous. The aim of the present study was to describe the use and complications of fAC-CVC in the trauma bay in two centers where they are routinely used.Methods: This was a retrospective analysis of routine fAC-CVC use from two French trauma centers. All patients admitted directly to the trauma resuscitation room were included. Demographic, clinical and biological data were collected from the scene to discharge to describe the use of catheters during initial trauma management including infectious, mechanical and thrombotic complications.Results: 243 pairs of femoral catheters were inserted among 692 patients admitted in both trauma centers. Femoral AC-CVC use was more frequent in critically ill patients with higher ISS 26 [17; 41] vs 13 [8; 24], p < 0.001(median [quartile 1-3]), severe traumatic brain injury (AIS head 1[0-4] vs 0[0-3], p < 0.001), lower systolic blood pressure, 92 (37) vs 113 (28) mmHg, p < 0.001 mean (standard deviation), lower haemoglobin on arrival, 10.9 (3) vs 13.3 (2.1) g/dL (p < 0.001), and higher blood lactate concentration, 4.0 (3.9) vs 2.1 (1.8) mmol/L (p < 0.001). In patients with fAC-CVC use time in the trauma room was longer, 46 [40;60] vs 30 [20;40] minutes (p < 0.05). In total 52 colonizations and 3 bloodstream infections were noted in 1000 catheter days. An incidence of 12% of mechanical complications and of 42% deep venous thromboses were observed. Of the latter none was associated with confirmed pulmonary embolism.Conclusion: Femoral AC-CVC appeared to be deployed more often in critically ill patients, presenting with shock and/or traumatic brain injury in particular. The observed rate of complications in this sample seems to be low compared to reported rates. [ABSTRACT FROM AUTHOR]

Résumé Les abcès hépatiques sont des affections rares et graves, dont l’incidence augmente ces dernières années en raison du vieillissement de la population, de l’avènement de la chirurgie pancréatique et hépatobiliaire en cancérologie et en transplantation, et de l’augmentation des facteurs d’immunodépression. Le tableau clinique étant très aspécifique, le diagnostic repose principalement sur l’imagerie et sur la ponction diagnostique. Le traitement est mal codifié, mais repose sur l’association d’une antibiothérapie prolongée, et d’un drainage. Liver abscess is a rare and severe infection. Incidence increases because of aging of population, advances in liver and biliary surgery including liver transplantation, and immunodeficiency factors. Diagnosis depends mainly on imaging and needle aspiration for microbiological identification. Treatment is based on antibiotics, percutaneous or surgical drainage, and control of the primary source. [ABSTRACT FROM AUTHOR]

Introduction Les survivants d’une ischémie mésentérique aiguë (IMA) nécessitent souvent une résection intestinale (RI). Le pronostic vital et fonctionnel ultérieur est mal connu. L’objectif de cette étude était de décrire la population des survivants d’une IMA et d’identifier des facteurs prédictifs de survie à long terme et de RI. Matériel et méthodes Étude observationnelle rétrospective de cohorte incluant tous les patients > 18 ans ayant survécu > 3 mois après une IMA suivis dans notre centre. Étude uni/multivariée des facteurs associés à la survie et à la RI. Résultats Entre 2006 et 2013, 164 patients ont été inclus. L’IMA était artérielle, veineuse et non-occlusive dans 63 %, 27 % et 3 % des cas. Une comorbidité cardiovasculaire ou thromboembolique était retrouvée dans 49 % des cas. Le 1 er dosage de lactates réalisé était normal dans 57 %. Avant la 1 ère RI, des signes de péritonite et une défaillance d’organe étaient retrouvés dans 60 % et 45 % des cas. Le traitement comprenait : anticoagulants, antibiotiques IV et/ou décontamination digestive orale (DDO) dans 87 %, 83 % et 19 % des cas. Quatre-vingt un pour cent des patients étaient admis en réanimation et 59 % nécessitaient une perfusion de noradrénaline. Les taux de RI et de syndrome de grêle court étaient de 83,5 % et 69,5 %. Après un suivi moyen de 54 [3–1314] mois, la survie globale était de 87 % et les taux de survie sans récidive d’IMA, sans entérostomie et sans nutrition parentérale étaient de 95 %, 76 % et 53 %. Les facteurs associés à la mortalité à 5 ans étaient l’âge ( p = 0,008) et la présence de comorbidités cardiovasculaires ( p = 0,006). En analyse univariée, les facteurs associés à une RI étaient : péritonite ( p < 0,0001), défaillance d’organe ( p = 0,002), hyperlactatémie ( p = 0002), les signes tomodensitométriques de nécrose intestinale ( p < 0,02) et l’absence de revascularisation en cas d’IMA ( p = 0,03). En analyse multivariée, les facteurs associés à la RI étaient : admission en réanimation ( p = 0,002), absence de DDO ( p = 0,0003) et de prise en charge initiale dans notre centre ( p = 0,0029). Discussion Nous confirmons la valeur pronostique péjorative des signes tardifs d’IMA, de l’absence de revascularisation artérielle et de DDO sur la RI. La normalité initiale des lactates et l’absence de terrain vasculaire connu n’excluent pas le diagnostic. La proportion élevée de patients réséqués mais sevrés de la nutrition parentérale justifie une prise en charge initiale agressive au mieux en centre spécialisé. [ABSTRACT FROM AUTHOR]

Introduction L’axe corticosurrénalien est un acteur important de la réponse physiologique lors des états de choc. Dans le choc septique, les modifications du volume surrénalien mesurées en tomodensitométrie (TDM) ont été identifiées comme facteur prédictif de mortalité [1] . Chez le polytraumatisé, une supplémentation en cortisone pourrait diminuer le nombre de pneumopathies acquises en réanimation [2] . L’objectif de ce travail était de décrire le volume surrénalien (VS) et sa capacité à prédire la défaillance d’organe à 24 h chez les patients traumatisés graves en choc hémorragique. Matériel et méthodes Il s’agit d’une étude bi-centrique, observationnelle et rétrospective, incluant tous les patients admis pour suspicion de traumatisme grave (TG). Les patients présentant un traumatisme crânien sévère (Glasgow Score < 8 à la prise en charge) étaient exclus. La mesure du VS (totale et indexé à taille) était réalisée sur le scanner corps entier initial par un radiologue ignorant le devenir du patient à l’aide d’un logiciel semi-automatique (Volume Viewer, GE Healthcare, États-Unis). Les patients étaient classés en 3 groupes : traumatisme grave en choc hémorragique (TGCH) défini par un Injury Severity Score (ISS) > 15 et transfusion > 4 concentrés érythrocytaires en moins de 6 h associée à une hypotension (pression artérielle systolique < 90 mmHg), TG défini par un ISS > 15 sans choc hémorragique et contrôle (C) défini par ISS < 16 sans choc. Les 3 groupes ont été appariés sur l’âge et le sexe. Les VS ont été comparés par un test de Student pour données appariées. Une régression linéaire a étudié l’association entre le VS et l’intensité de la défaillance d’organe dans les premières 24 h évaluée par le SOFA (Sequencial Organ Failure Assessment) à 24 h. Les résultats sont exprimés en médianes et quartiles [1,3]. Résultats Parmi les patients, 263 ont été inclus (TGCH : n = 84, TG : n = 89, C : n = 90). L’ISS des groupes TGCH, TG et C était respectivement de 38 [27,50], 22 [18,27] et 9 [4,10] ( p < 0,001). Le SOFA à 24 h des groupes TGCH, TG et C était respectivement à 9 [7,12], 2 [0,5] et 0 [0,1] ( p < 0,001). Les VS (total et indexée) dans les 3 groupes sont représentés sur la Fig. 1 . Il n’existait pas de corrélation entre VS total et indexé à l’admission et le SOFA à 24 h ( r 2 = 0,04 pour VS et r 2 = −0,05 pour VS indexé à la taille) ( Fig. 1 ). Discussion Contrairement au choc septique, la présence d’un choc hémorragique chez le TG n’est pas associée à une modification précoce du volume surrénalien mesuré sur la TDM à l’admission. De plus, il n’est pas corrélé à la gravité clinique à 24 h. Il serait intéressant de répéter la mesure à 48 h pour poursuivre cette évaluation. [ABSTRACT FROM AUTHOR]

Purpose: Acute mesenteric ischemia (AMI) may be underdiagnosed when not clinically suspected before CT is performed. We assessed the influence of a clinical suspicion of AMI on the CT accuracy.Method: This retrospective single-centre study included patients who underwent CT in 2014-2019 and had clinically suspected AMI and/or confirmed AMI. CT protocols were adapted based on each patient's presentation and on findings from unenhanced images. The CT protocol was considered optimal for AMI when it included arterial and portal venous phases. CT protocols, accuracy of reports, and outcomes were compared between the groups with and without suspected AMI before CT.Results: Of the 375 events, 337 (90 %) were suspected AMI and 66 (18 %) were AMI, including 28 (42 %) with and 38 without suspected AMI. These two groups did not differ significantly regarding the medical history, clinical presentation, or laboratory tests. The CT protocol was more often optimal for AMI in the group with suspected AMI (26/28 [93 %] vs. 28/38 [74 %], p = 0.046). Diagnostic accuracy was not different between groups with and without suspected AMI (26/28 [93 %] vs. 34/38 [90 %], p = 1.00). However, it was lower in the group without suspicion of AMI when the CT protocol was not optimal for AMI (27/28 [96 %] vs 7/10 [70 %], p = 0.048).Conclusions: The negative influence of not clinically suspecting AMI can be mitigated by using a tailored CT protocol. [ABSTRACT FROM AUTHOR]