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Background: This study aimed to investigate renal replacement therapy (RRT) practices in a representative nationwide sample of French intensive care units (ICUs). Methods: From July 1 to October 5 2021, 67 French ICUs provided data regarding their ICU and RRT implementation. We used an online questionnaire to record general data about each participating ICU, including the type of hospital, number of beds, staff ratios, and RRT implementation. Each center then prospectively recorded RRT parameters from 5 consecutive acute kidney injury (AKI) patients, namely the indication, type of dialysis catheter used, type of catheter lock used, type of RRT (continuous or intermittent), the RRT parameters initially prescribed (dose, blood flow, and duration), and the anticoagulant agent used for the circuit. Results: A total of 303 patients from 67 ICUs were analyzed. Main indications for RRT were oligo-anuria (57.4%), metabolic acidosis (52.1%), and increased plasma urea levels (47.9%). The commonest insertion site was the right internal jugular (45.2%). In 71.0% of cases, the dialysis catheter was inserted by a resident. Ultrasound guidance was used in 97.0% and isovolumic connection in 90.1%. Citrate, unfractionated heparin, and saline were used as catheter locks in 46.9%, 24.1%, and 21.1% of cases, respectively. Conclusions: Practices in French ICUs are largely compliant with current national guidelines and international literature. The findings should be interpreted in light of the limitations inherent to this type of study.

Les patients qui survivent après un séjour en réanimation sont susceptibles de présenter des symptômes regroupés sous le terme de Syndrome Post-Soins Intensifs (PICS en Anglais). Ce syndrome met en lumière l’implication de chacune de ses dimensions dans les principales sphères de la vie quotidienne des patients (vie familiale et sociale, activité professionnelle ou privée…ressources économiques). A côté du PICS, il faut souligner l’impact des Inégalités Sociales de Santé (ISS) et notamment de la précarité sur l’accès aux soins, le retour au domicile et sur la qualité de vie des patients en post-réanimation. La réanimation a également dans certaines situations eu un impact sur le retour à l’emploi des patients survivants et plus globalement sur le revenu de la famille avec parfois une tendance à l’isolement social et au repli sur soi. Un certain nombre de réflexions ont été menées dans de nombreux pays pour anticiper (rôle de l’assistante sociale en France…) et suivre les conséquences socio-économiques après un séjour en réanimation (consultations post-réanimation, groupe et plateforme d’entraides…etc). En revanche, nous manquons en France d’indicateurs fiables et reconnus qui permettraient de proposer un accompagnement personnalisé, médical et social, afin de limiter les conséquences socioéconomiques pour les patients en post-réanimation, source potentielle d’accroissements des ISS.

Background: Smoking influence on poststroke prognosis remains controversial. These conflicting results could be due to some residual confounding factors not fully considered in previous studies, including social deprivation. This study aimed to assess the joint impact of deprivation and smoking on functional outcomes after ischemic stroke. Methods: Between 2011 and 2014, 1,573 patients with a first-ever stroke were prospectively included in the French multicenter INDIA (“Inegalites sociales et pronostic des accidents vasculaires cerebraux à Dijon et Antilles-Guyane”) cohort study. Patients with ischemic stroke and available data on smoking, deprivation, and outcome were considered for the analysis (n = 1,242). Deprivation was assessed using the EPICES “Evaluation de la Précarité et des Inégalites de santé dans les Centres d’Examen de Santé” score. Primary outcome was functional outcome assessed with the modified Rankin Scale (mRS) score at 12 months. Association between smoking and moderate to severe disability (mRS score ≥3) was evaluated with logistic regression model. Interactions between smoking and deprivation were tested. Results: Smokers (n = 189, 15.2%) were younger and more often deprived (EPICES score ≥30.17) than nonsmokers. A significant interaction was found between smoking status and deprivation on disability (p = 0.003). In nondeprived patients, the odds of moderate to severe disability at 12 months were twice as high in smokers as in nonsmokers (adjusted OR = 2.08, 95% CI: 1.04–4.18). This association was not observed in deprived patients (adjusted OR = 0.89, 95% CI: 0.49–1.61). Conclusion: The effect of smoking on functional prognosis after ischemic stroke varied according to deprivation status, with poorer outcomes observed in nondeprived patients.

Resume Introduction La fistule anastomotique est la complication redoutee apres chirurgie colorectale. De nombreux travaux ont montre l’interet du dosage de la CRP en postoperatoire comme marqueur diagnostic precoce. Le seuil critique des marqueurs biologiques de l’inflammation doit-il rester le meme que la resection soit colique ou rectale ? Patients et methode Il s’agit d’une etude basee sur une cohorte constituee entre 2011 et 2014, incluant 497 patients avec une resection colorectale programmee. La proteine C-reactive et la pro-calcitonine ont ete mesurees tous les jours entre la veille et le 4e jour. Toutes les complications postoperatoires intra-abdominales ont ete considerees comme une fistule anastomotique. Les seuils de detection ont ete calcules a partir de l’aire sous la courbe ROC. Resultats Une complication septique intra-abdominale est survenue chez 16,9 % des operes d’une resection rectale contre 9,9 % apres colectomie (p = 0,03). Il n’existe pas de difference significative en termes de reponse inflammatoire postoperatoire entre les deux groupes en l’absence de complications, tant sur la CRP que la PCT. Apres resection rectale, la meilleure aire sous la courbe (AUC = 0,87) correspond a la CRP de j4 pour un seuil de 100 mg/L : sensibilite 83,3 %, une VPN 95,3 %. Pour les colons avec la meme CRP a 100 mg/L (AUC = 0,71), la sensibilite est de 63,6 % et la VPN de 93,9 %. Conclusion Malgre une chirurgie plus a risque, le seuil de detection de la fistule anastomotique apres chirurgie rectale reste le meme : CRP > 100 mg/L a j4.

Summary Introduction Anastomotic fistula is the most fearsome complication following colorectal surgery. Numerous studies have demonstrated the interest of postoperative CRP assay as an early diagnostic marker. Must the critical threshold for biological inflammatory markers remain the same, whether resection be colic or rectal? Patients and method This is a study based on a cohort constituted between 2011 and 2014, including 497 patients with planned colorectal resection. C-reactive protein and pro-calcitonin were measured daily from day before surgery to D4. All postoperative intra-abdominal complications were considered as an anastomotic fistula. Detection thresholds were calculated from the area under the ROC curve. Results An intra-abdominal septic complication occurred in 16.9% of the patients having undergone rectal resection vs. 9.9% of those having had colectomy (P = 0.03). In the absence of complications there was no significant difference between the two groups in terms of postoperative inflammatory response as determined by either CRP or PCT assay. Following rectal resection, optimal area under the curve (AUC = 0.87) corresponds to CRP on D4 for a threshold of 100 mg/L: sensitivity 83.3%, NPV 95.3%. For colons with the same CRP at 100 mg/L (AUC = 0.71): sensitivity 63.6%, NPV 93.9%. Conclusion Notwithstanding riskier surgery, the detection threshold for an anastomotic fistula following rectal surgery remains the same: CRP > 100 mg/L at D4.

Cette étude qualitative s’intéresse à l’effet de la pratique du Jiujitsu brésilien (JJB) sur la santé mentale et ses mécanismes sous-jacents. Les écrits scientifiques sur les arts martiaux indiquent que ceux-ci pourraient favoriser une meilleure santé mentale en diminuant les symptômes anxieux et dépressifs. L’entrevue semi-dirigée dans le cadre de cette étude permet aux participants de discuter les effets de leur pratique du JJB sur leur santé mentale et les mécanismes sous-jacents. Les dix participants sont des adultes âgés d’au moins 18 ans qui ont complété le General Anxiety Disorder (GAD-7), le Patient Health Questionnaire (PHQ-9) ainsi que le World Health Organization Quality of Life abrégé (WHOQOL-BREF). Les participants rapportent que la pratique du JJB améliorerait leur santé mentale de par ses effets sur leur réseau social, leur sentiment d’auto-efficacité et la gestion de leurs émotions négatives. Lorsque les participants mentionnent des éléments négatifs associés au JJB, ils sont principalement attribués à l’arrêt de la pratique du sport. Les résultats de cette étude pourront guider la réalisation d’une étude quantitative plus large sur ce sujet et servir de base pour développer des stratégies afin d’optimiser l’effet de la pratique du JJB sur la santé mentale.

Summary Objective This pragmatic, multicenter, open-label, randomized controlled trial (RCT) aimed to compare the effectiveness, safety, and cost–utility of a custom-made knee brace versus usual care over 1 year in medial knee osteoarthritis (OA). Design 120 patients with medial knee OA (VAS pain at rest >40/100), classified as Kellgren–Lawrence grade II-IV, were randomized into two groups: ODRA plus usual care (ODRA group) and usual care alone (UCA group). The primary effectiveness outcome was the change in VAS pain between M0 and M12. Secondary outcomes included changes over 1 year in KOOS (function) and OAKHQOL (quality of life) scores. Drug consumption, compliance, safety of the knee brace, and cost–utility over 1 year were also assessed. Results The ODRA group was associated with a higher improvement in: VAS pain (adjusted mean difference of −11.8; 95% CI: −21.1 to −2.5); all KOOS subscales (pain: +8.8; 95% CI: 1.4–16.2); other symptoms (+10.4; 95% CI: 2.7–18); function in activities of daily living (+9.2; 95% CI: 1.1–17.2); function in sports and leisure (+12.3; 95% CI: 4.3–20.3); quality of life (+9.9; 95% CI: 0.9–15.9), OAKHQOL subscales (pain: +14.8; 95% CI: 5.0–24.6); and physical activities (+8.2; 95% CI: 0.6–15.8), and with a significant decrease in analgesics consumption at M12 compared with the UCA group. Despite localized side-effects, observance was good at M12 (median: 5.3 h/day). The ODRA group had a more than 85% chance of being cost-effective for a willingness-to-pay threshold of €45 000 per QALY. Conclusions The ERGONOMIE RCT demonstrated significant clinical benefits of an unloader custom-made knee brace in terms of improvements in pain, function, and some aspects of quality of life over 1 year in medial knee OA, as well as its potential cost–utility from a societal perspective.

International audience; Lipopolysaccharide (LPS) is a key player for innate immunity activation. It is therefore a prime target for sepsis treatment, as antibiotics are not sufficient to improve outcome during septic shock. An extracorporeal removal method by polymyxin (PMX) B direct hemoperfusion (PMX-DHP) is used in Japan, but recent trials failed to show a significant lowering of circulating LPS levels after PMX-DHP therapy. PMX-DHP has a direct effect on LPS molecules. However, LPS is not present in a free form in the circulation, as it is mainly carried by lipoproteins, including LDLs. Lipoproteins are critical for physiological LPS clearance, as LPSs are carried by LDLs to the liver for elimination. We hypothesized that LDL apheresis could be an alternate method for LPS removal. First, we demonstrated in vitro that LDL apheresis microbeads are almost as efficient as PMX beads to reduce LPS concentration in LPS-spiked human plasma, whereas it is not active in PBS. We found that PMX was also adsorbing lipoproteins, although less specifically. Then, we found that endogenous LPS of patients treated by LDL apheresis for familial hypercholesterolemia is also removed during their LDL apheresis sessions, with both electrostatic-based devices and filtration devices. Finally, LPS circulating in the plasma of septic shock and severe sepsis patients with gram-negative bacteremia was also removed in vitro by LDL adsorption. Overall, these results underline the importance of lipoproteins for LPS clearance, making them a prime target to study and treat endotoxemia-related conditions.

IntroductionPrognosis of patients with COVID-19 depends on the severity of the pulmonary affection. The most severe cases may progress to acute respiratory distress syndrome (ARDS), which is associated with a risk of long-term repercussions on respiratory function and neuromuscular outcomes. The functional repercussions of severe forms of COVID-19 may have a major impact on quality of life, and impair the ability to return to work or exercise. Social inequalities in healthcare may influence prognosis, with socially vulnerable individuals more likely to develop severe forms of disease. We describe here the protocol for a prospective, multicentre study that aims to investigate the influence of social vulnerability on functional recovery in patients who were hospitalised in intensive care for ARDS caused by COVID-19. This study will also include an embedded qualitative study that aims to describe facilitators and barriers to compliance with rehabilitation, describe patients’ health practices and identify social representations of health, disease and care.Methods and analysisThe "Functional Recovery From Acute Respiratory Distress Syndrome (ARDS) Due to COVID-19: Influence of Socio-Economic Status" (RECOVIDS) study is a mixed-methods, observational, multicentre cohort study performed during the routine follow-up of post-intensive care unit (ICU) functional recovery after ARDS. All patients admitted to a participating ICU for PCR-proven SARS-CoV-2 infection and who underwent chest CT scan at the initial phase AND who received respiratory support (mechanical or not) or high-flow nasal oxygen, AND had ARDS diagnosed by the Berlin criteria will be eligible. The primary outcome is the presence of lung sequelae at 6 months after ICU discharge, defined either by alterations on pulmonary function tests, oxygen desaturation during a standardised 6 min walk test or fibrosis-like pulmonary findings on chest CT. Patients will be considered to be socially disadvantaged if they have an "Evaluation de la Précarité et des Inégalités de santé dans les Centres d’Examen de Santé" (EPICES) score ≥30.17 at inclusion.Ethics and disseminationThe study protocol and the informed consent form were approved by an independent ethics committee (Comité de Protection des Personnes Sud Méditerranée II) on 10 July 2020 (2020-A02014-35). All patients will provide informed consent before participation. Findings will be published in peer-reviewed journals and presented at national and international congresses.Trial registration numberNCT04556513

BACKGROUND Social deprivation may have a deleterious influence on post-stroke outcomes, but available data in the literature are mixed. AIM The aim of this cohort study was to evaluate the impact of social deprivation on 1-year survival in patients with first-ever stroke. METHODS Social deprivation was assessed at individual level with the EPICES score, a validated multidimensional questionnaire, in 1312 patients with ischemic stroke and 228 patients with spontaneous intracerebral hemorrhage, who were prospectively enrolled in six French study centers. Baseline characteristics including stroke severity and pre-stroke functional status were collected. Multivariable Cox models were generated to evaluate the associations between social deprivation and survival at 12 months in ischemic stroke and intracerebral hemorrhage separately. RESULTS A total of 819 patients (53.2%) were socially deprived (EPICES score ≥ 30.17). In ischemic stroke, mortality at 12 months was higher in deprived than in non-deprived patients (16% vs. 11%, p = 0.006). In multivariable analyses, there was no association between deprivation and death occurring within the first 90 days following ischemic stroke (adjusted hazard ratio [aHR] 0.81, 95% CI 0.54-1.22, p = 0.32). In contrast, an excess in mortality was observed between 90 days and 12 months in deprived compared with non-deprived patients (aHR 1.97, 95% CI 1.14-3.42, p = 0.016). In patients with intracerebral hemorrhage, mortality at 12 months did not significantly differ according to deprivation status. CONCLUSIONS Social deprivation was associated with delayed mortality in ischemic stroke patients only and, although the exact underlying mechanisms are still to be identified, our findings suggest that deprived patients in particular may benefit from an optimization of post-stroke care.

Background French Guiana has the highest incidence of ischemic and hemorrhagic stroke of all French territories. However, there is no further information on the epidemiology and management of stroke in French Guiana. Our goal was to describe the characteristics of patients in French Guiana in order to generate hypotheses regarding the determinants explaining the magnitude of this public health problem. Methods We used the data of the French multicentre INDIA prospective cohort study which included consecutive patients aged > 18 years with a first-ever stroke from June 2011 to October 2014. For the present study, only patients with ischemic or hemorrhagic stroke admitted in one of the 3 participating hospitals were analyzed. Results Among the 298 patients (mean age 62.2 ± 14.5 years, 63.7% man) included in French Guiana, 52% were born abroad. Most strokes were ischemic strokes (79%), 14% of which were thrombolyzed. Hypertension (70.2%), history of smoking (22%) and diabetes (25%) were the most common risk factors and 28.4% of patients had known but untreated hypertension. Overall 89 (38%) patients with ischemic stroke were admitted less than 4.5 h after the first symptoms. In-hospital mortality was greater for intracerebral hemorrhage (18.7%) than for ischemic stroke (4.2%). Overall, 84.5% had health insurance coverage and among these, 41.9% had CMU, the universal health insurance for the poor. Conclusions The present study is the first epidemiologic description of stroke in French Guiana. The comparisons of these results show that stroke patients in French Guiana are epidemiologically atypical because they are younger, and more likely to be males than patients in mainland France. Stroke risk factors and delay between stroke and hospital admission were comparable with what is observed in France, suggesting that efforts should focus on primary care and social inequalities of health to alleviate the main determinants of stroke in French Guiana.

Several studies have investigated the influence of body mass index (BMI) on functional gain after total hip replacement (THR) or total knee replacement (TKR) in osteoarthritis, with contradictory results. This systematic literature review was conducted to ascertain whether obesity affects functional recovery after THR or TKR in the short (1 year), medium (3 years) and long term (3 years).The study was registered with PROSPERO and conducted according to the PRISMA guidelines. A systematic literature search was conducted across Medline and EMBASE databases for articles published between 1980 and 2020 that investigated patient-reported measures of functional recovery after THR and TKR in participants with osteoarthritis and obesity (defined as BMI ≥30 kg/mTwenty-six articles reporting on 68,840 persons (34,955 for THR and 33,885 for TKR) were included in the final analysis: 5 case-control studies, 21 cohort studies (9 for THR only, 10 for TKR only and 2 for both). The average minimum follow-up was 36.4 months, ranging from 6 weeks to 10 years. Most studies found significantly lower pre-operative patient-reported functional scores for participants with obesity. After THR, there was a small difference in functional recovery in favor of those without obesity in the short term (6 months), but the difference remained below the minimal clinically important difference (MCID) threshold and disappeared in the medium and long term. After TKR, functional recovery was better for those with obesity than those without in the first year, similar until the third year, and then decreased thereafter.Although there is a paucity of high-quality evidence, our findings show substantial functional gains in people with obesity after total joint replacement. Functional recovery after THR or TKR does not significantly differ, or only slightly differs, between those with and without obesity, and the difference in functional gain is not clinically important.CRD42018112919.

Background While its importance in daily living, the anaerobic metabolism is not taken into account in clinical practice. The lack of validated functional performance tests for patients with chronic disabilities may explain this defect. In this context, the Short and Fast Step Test (SFST) was recently developed and validated in healthy volunteers. Aim The purpose of this study was to investigate the safety, feasibility and reliability of the SFST, a functional test exploring anaerobic metabolism in coronary patients during cardiac rehabilitation. Design This study was a monocentric prospective study. Settings This study took place in the rehabilitation center of the University Hospital Center of Dijon, France. Population 44 coronary patients, addressed for a first cardiac rehabilitation, were included in this protocol. Methods All participants performed three SFST: T1 and T2 (including respiratory gas exchange) the first day of the program and T3 after 3 to 7 days. SFST consists of walking up and down a 17.5cm-high step as many times as possible in 1 minute. Safety was assessed by the percentage of patients who performed the SFST without reporting a fall, or muscular or cardiovascular events. Feasibility was evaluated by the percentage of patients who succeeded in doing the SFST. Reliability was assessed with the number of raised steps in same condition (T1-T3) and different conditions (T1-T2) using a 2-way intraclass correlation coefficient (ICC). Values were given with their 90% confidence interval [90%CI]. Results The safety was 95.2% [85.8;99.2] for T1, 88.1% [76.6;95.2] for T2 and 90.4% [79.5;96.7] for T3. 100% [93,1;100] of participants completed T1 and T2, 92.9% [82.6;98] T3. An ICC of 0.74 [0.60;0.84] was observed between T1 and T3 and of 0.87 [0.79;0.92] between T1 and T2. Conclusions This study demonstrates the good safety, feasibility and reliability of the SFST to assess anaerobic metabolism in coronary patients in a rehabilitation program. Clinical rehabilitation impact These results show that the SFST seems suitable for the evaluation of brief submaximal functional capacity in daily activities. It offers a real possibility to assess such capacity during the cardiac rehabilitation routine.

Objective The main objective was to compare estimated walking perimeter (WP) and actual WP during a free walking test (6-minute walk test [6MWT]) in patients with lumbar spinal stenosis (LSS). The second objective was to describe the correlation between measured gait parameters and functional parameters. Methods This was a single-center prospective study including 38 patients with symptomatic LSS (23 men, 15 women; mean age, 69.3 ± 7.9 years). The intervention was the 6MWT. For the main outcome measure, patients were first asked to verbally estimate their WP. Then, WP was evaluated using a 6MWT at a self-selected speed. In the absence of need to stop, and if a distance of 500 m was not reached, the test was extended to this distance. Specific functional scores (Oswestry Disability Index and Quebec Back Pain Disability Scale) were recorded, and a quality of life questionnaire was completed. Results WP was estimated to be less than 500 m in 21 of 38 patients, but only 7 patients actually stopped walking before reaching 500 m. The median estimate error in these patients was 200 m (interquartile range, 65–250). The shorter the estimated distance was, the greater the estimation error (r = −0.63, P = 0.002). The average walking speed was slow. Functional parameters (Oswestry Disability Index and Quebec Back Pain Disability Scale) were weakly and inversely correlated with real WP (r = −0.44 and r = −0.31, respectively) and moderately inversely correlated with measured walking speed (r = −0.51, P ≤ 0.001 for both). Conclusions Direct measurement of free walking speed should be considered as a valid functional assessment in current practice for patients with LSS instead of estimated WP. To assist therapeutic decision-making, the most relevant type of walking test (duration, distance, velocity) needs to be determined.

Bien que l’anxiété soit très répandue chez les personnes souffrant d’un trouble bipolaire et qu’elle ait des impacts délétères sur l’évolution et le traitement de la maladie, des recensions des écrits antérieures ont souligné que de nombreux aspects de cette condition demeurent sous-étudiés (Provencher et al., 2012 ; Spoorthy et al., 2019). La présente étude de portée (scoping review) vise à fournir un portrait complet de la littérature traitant de l’anxiété dans le trouble bipolaire (ATB) entre 2011 et 2020, à évaluer si l’intérêt pour le sujet a augmenté au cours de la dernière décennie et à cartographier les tendances de publication. Trois bases de données ont été consultées, tous les articles ont été triés sur la base du titre et du résumé, et un échantillon aléatoire correspondant à 25 % des articles restants a été constitué en vue d’évaluer leur éligibilité (n = 406 articles). De ces derniers, 247 articles ont été inclus. Les 75 % restants (n = 1217 articles) sont en processus de catégorisation et les résultats finaux seront présentés dans une publication ultérieure. Le nombre annuel d’articles sur l’ATB publiés entre 2011 et 2020 a été calculé et les articles traitant du sujet en tant que sujet principal ont été classés en 4 catégories et 11 sous-catégories afin d’identifier les lacunes dans les connaissances sur le sujet. Les résultats préliminaires (basés sur l’échantillon de 25 %) indiquent que le nombre annuel de publications est resté relativement stable au cours de la période et que seulement 33,6 % des articles font de l’ATB leur sujet principal. Parmi ceux-ci, plus de 50 % sont de nature descriptive, couvrant principalement les impacts observables de la comorbidité et ses caractéristiques cliniques. Une proportion plus faible de la littérature aborde les processus sous-jacents à l’ATB (14,5 %) et son traitement (22,9 %). Ces résultats soulèvent des interrogations quant à la pertinence de continuer à investir des ressources dans la recherche portant sur les aspects descriptifs du sujet alors que l’on en sait encore peu sur les mécanismes sous-jacents à l’ATB et sur son traitement. Les résultats soulignent la nécessité de poursuivre les recherches sur ces autres aspects de l’ATB afin de mieux comprendre et traiter cette comorbidité unique.

Lipopolysaccharide (LPS) is a key player for innate immunity activation. It is therefore a prime target for sepsis treatment, as antibiotics are not sufficient to improve outcome during septic shock. Extracorporeal removal method by polymyxin B hemoperfusion (PMX-DHP) is used in Japan, but recent trials failed to show a significant lowering of circulating LPS levels after PMX-DHP therapy. PMX-DHP has a direct effect on LPS molecules. However, LPS is not present in a free form in the circulation, as it is mainly carried by lipoproteins, including low density lipoproteins (LDL). Lipoproteins are critical for physiological LPS clearance, as LPS are carried by low density lipoproteins (LDL) to the liver for elimination. We hypothesized that LDL-apheresis can be an alternate method for LPS removal. We demonstrated first in vitro that LDL apheresis microbeads are almost as efficient as PMX beads to reduce LPS concentration in LPS-spiked human plasma, whereas it is not active in phosphate-buffered saline. We found that PMX was also adsorbing lipoproteins, although less specifically. Then, we found that endogenous LPS of patients treated by LDL-apheresis for familial hypercholesterolemia is also removed during their LDL-apheresis sessions, both with electrostatic-based devices and filtration devices. Finally, LPS circulating in the plasma of septic shock and severe sepsis patients with gram-negative bacteremia was also removed in vitro by LDL adsorption. Overall, these results underline the importance of lipoproteins for LPS clearance, making them a prime target to study and treat endotoxemia-related conditions.

Introduction Our objective was to develop and to evaluate a system to measure latency and threshold of pendular motion perception based on a swinging bed. Materials and methods This prospective study included 30 healthy adults (age: 32 ± 12 years). All subjects were tested twice with a 10 min. interval. A second trial was conducted 2 to 15 days after. A rehabilitation swinging bed was connected to an electronic device emitting a beep at the beginning of each oscillation phase with an adjustable time lag. Subjects were blindfolded and auditory cues other than the beep were minimized. The acceleration threshold was measured by letting the bed oscillate freely until a natural break and asking the patient when he did not perceive any motion. The perception latency was determined by asking the patient to indicate whether the beep and the peak of each oscillation were synchronous. The time lag between sound and peak of the head position was swept from -750 to +750 ms by 50 ms increments. Results The mean acceleration threshold was 9.2±4.60 cm/s2. The range width of the synchronous perception interval was estimated as 535±190 ms. The point of subjective synchronicity defined as the center of this interval was -195±106 ms (n = 30). The test-retest evaluation in the same trial showed an acceptable reproducibility for the acceleration threshold and good to excellent for all parameters related to sound-movement latency. Conclusion Swinging bed combined to sound stimulation can provide reproducible information on movement perception in a simple and non-invasive manner with highly reproducible results.

Background The influence of socioeconomic status on patient outcomes is unclear. We assessed the impact of socioeconomic deprivation on severity of illness at intensive care unit (ICU) admission, and on the risk of death at 3 months after ICU admission. Methods The IVOIRE study was a prospective, observational, multicentre cohort study in the ICU of 8 participating hospitals in France, including patients aged ≥ 18 years admitted to the ICU and receiving at least one life support therapy for organ failure. The primary outcomes were severity at admission (assessed by SAPSII score), and mortality at 3 months. Socioeconomic data were obtained from interviews with patients or family. Deprivation was assessed using the EPICES score. Results Among 1294 patents included between 2013 and 2016, 629 (48.6%) were classed as deprived and differed significantly from non-deprived subjects in terms of sociodemographic characteristics and pre-existing conditions. The mean SAPS II score at admission was 50.1 ± 19.4 in deprived patients and 52.3 ± 17.3 in non-deprived patients, with no significant difference by multivariable analysis (β = − 1.85 [95% CI − 3.86; + 0.16, p = 0.072]). The proportion of death was 31.1% at 3 months, without significant differences between deprived and non-deprived patients, even after adjustment for confounders. Conclusions Deprivation is frequent in patients admitted to the ICU and is not associated with disease severity at admission, or with mortality at 3 months between deprived and non-deprived patients. Trial registration The IVOIRE cohort is registered with ClinicalTrials.gov under the identifier NCT01907581, registration date 17/7/2013

Septic shock is the primary cause of death in intensive care units, with about 20% of patients dying in the first 3 days. To design future trials focused on early mortality, we require knowledge of early indicators that can detect patients at high risk of early death from refractory septic shock.The aim of this study was to assess whether the cumulative dose of vasopressors (CDV), calculated as the cumulative dose of epinephrine + norepinephrine, is a predictor of early death (within 72 hours) attributable to refractory septic shock (EDASS). This substudy of the EPISS trial was based on 370 patients admitted to a French ICU for septic shock between 2009 and 2011. The area under the receiving operating characteristic (ROC) curve was calculated for the CDV at 6, 12, 24, 36, and 48 hours after vasopressor initiation, and a strategy to predict the risk of EDASS was built based on selected times and thresholds.Among the 370 patients included, 51 (14%) died within the first 72 hours with 40 (11%) EDASS. A strategy in two steps (CDV ≥ 800 μg/kg at 6 hours and/or CDV ≥ 2600 μg/kg at 24 hours) was able to predict EDASS with sensitivity of 45%, specificity 97%, positive predictive value 78% and negative predictive value 94%. Overall, our results confirm that early death directly attributable to septic shock could be effectively predicted by the CDV in the first hours of treatment. These results will help to select patients eligible for innovative therapies aimed at improving early mortality in septic shock.

Resume Introduction Les concentrations seriques de proteine C reactive (CRP) en deca d’un seuil predefini entre le 3e et le 5e jour postoperatoire sont un marqueur fiable de l’absence de complication infectieuse apres chirurgie colorectale. Cependant, la strategie a mettre en place en cas de CRP elevee n’est pas codifiee. Le but de ce travail etait d’analyser l’utilite du scanner dans cette situation au sein d’une cohorte prospective de chirurgie colorectale reglee. Methodes Entre novembre 2011 et avril 2015, les patients ayant une CRP > 125 mg/L au 4e jour postoperatoire d’une resection colorectale reglee dans l’un des 2 centres participants ont ete inclus prospectivement dans une base. Toutes les complications survenues pendant les 30 j suivant l’intervention, leur mode de diagnostic, prise en charge et evolution ont ete recueillies. La realisation d’un scanner entre le 4e et le 6e jour guide par la seule elevation de la CRP, en l’absence de tout autre signe clinique, a ete etudiee pour evaluer ainsi sa rentabilite diagnostique. Des analyses uni- et multivariees ont ete realisees pour identifier les facteurs de risque d’infection postoperatoire. Resultats Au total, 174 patients ont ete inclus : 56 (32,1 %) ont eu un scanner entre le 4e et le 6e jour, qui a permis de detecter une complication postoperatoire dans 55,4 % des cas. Les patients n’ayant pas eu de scanner avaient des valeurs de CRP plus basses (163 vs 185,5, p = 0,02). Parmi les 118 patients n’ayant pas eu de scanner, 50,8 % ont presente une complication infectieuse a terme. La sensibilite du scanner guide par la CRP etait de 76,7 % et la valeur predictive negative de 78,8 %. Conclusion En presence d’une CRP elevee au 4e jour postoperatoire un scanner abdomino-pelvien doit etre realise. Un resultat normal n’elimine pas formellement l’existence d’une complication intra-abdominale. En cas de persistance de l’inflammation dans les deux jours suivants, une reprise chirurgicale systematique doit etre comparee a un nouveau scanner dans le cadre d’un protocole.

Objective Intra-abdominal infections (IAIs) after elective colorectal surgery impact significantly the short- and long-term outcomes. In the era of fast-track surgery, they often come to light after discharge from hospital. Early diagnosis is therefore essential. C-reactive protein levels have proved to be accurate in this setting. Procalcitonin has been evaluated in several studies with conflicting results. This meta-analysis aimed to compare the predictive abilities of C-reactive protein and procalcitonin in the occurrence of IAIs after elective colorectal surgery. Methods This meta-analysis included studies analyzing C-reactive protein and/or procalcitonin levels at postoperative days 2, 3, 4, and/or 5 as markers of intra-abdominal infection after elective colorectal surgery. Methodological quality was assessed by the QUADAS2 tool. The area under the curve summary receiver-operating characteristic was calculated for each day and each biomarker, using a random-effects model in cases of heterogeneity. Results The meta-analysis included 11 studies (2692 patients). An IAI occurred in 8.9% of the patients. On postoperative day 3, area under the curve was 0.80 (95% CI, 0.76-0.85) for C-reactive protein and 0.78 (95% CI, 0.68-0.87) for procalcitonin. On postoperative day 5, their predictive accuracies were 0.87 (95% CI, 0.80-0.93) and 0.90 (95% CI, 0.82-0.98), respectively. The accuracy of C-reactive protein and procalcitonin did not differ at any postoperative day. Conclusions Levels of inflammatory markers under the cutoff value between postoperative days 3 and 5 ensure safe early discharge after elective colorectal surgery. Procalcitonin seems not to have added value as compared to C-reactive protein in this setting.

Highlights • 6% of acute respiratory infections were linked to human metapneumovirus. • High heterogeneity was observed. • HMPV should be taken into account as a possible etiology in hospitalized ARI., This meta-analysis aimed to estimate the prevalence of human metapneumovirus (hMPV) infections in patients hospitalized for acute respiratory infection (ARI) and to study factors associated with this prevalence. Medline and ScienceDirect databases were searched for prospective observational studies that screened hospitalized patients with ARI for hMPV by RT-PCR, with data available at December 27, 2014. The risk of bias was assessed regarding participation rate, definition of ARI, description of diagnostic technique, method of inclusion identical for all subjects, standardized and identical sampling method for all subjects, analysis performed according to the relevant subgroups, and presentation of data sources. Random-effect meta-analysis with arcsine transformation and meta-regressions was used. In the 75 articles included, the prevalence of hMPV among hospitalized ARI was 6.24% (95% CI 5.25–7.30). An effect of the duration of the inclusion period was observed (p = 0.0114), with a higher prevalence of hMPV in studies conducted during periods of 7–11 months (10.56%, 95% CI 5.97–16.27) or complete years (7.55%, 95% CI 5.90–9.38) than in periods of 6 months or less (5.36%, 95% CI 4.29–6.54). A significant increase in the incidence with increasing distance from the equator was observed (p = 0.0384). hMPV should be taken into account as a possible etiology in hospitalized ARI.

Intra-abdominal infections are frequent and life-threatening complications after colorectal surgery. An early detection could diminish their clinical impact and permit safe early discharge.This study aimed to find the most accurate marker for the detection of postoperative intra-abdominal infection and the appropriate moment to measure it.A prospective, observational study was conducted in 3 centers. Consecutive patients undergoing elective colorectal surgery with anastomosis were included. C-reactive protein and procalcitonin were measured daily until the fourth postoperative day. Postoperative infections were recorded according to the definitions of the Centres for Diseases Control. The areas under the receiver operating characteristic curve were analyzed and compared to assess the diagnostic accuracy of each marker.Five-hundred and one patients were analyzed. The incidence of intra-abdominal infection was 11.8%, with 24.6% of patients presenting at least one infectious complication. Overall mortality was 1.2%. At the fourth postoperative day, C-reactive protein was more discriminating than procalcitonin for the detection of intra-abdominal infection (areas under the ROC curve: 0.775 vs 0.689, respectively, P = 0.03). Procalcitonin levels showed wide dispersion. For the detection of all infectious complications, C-reactive protein was also significantly more accurate than procalcitonin on the fourth postoperative day (areas under the ROC curve: 0.783 vs 0.671, P = 0.0002).C-reactive protein is more accurate than procalcitonin for the detection of infectious complications and should be systematically measured at the fourth postoperative day. It is a useful tool to ensure a safe early discharge after elective colorectal surgery.

IF 2.766; International audience; IntroductionTo reduce the occurrence of complications in the setting of high-risk patients with contaminated operative field, a wide range of biologic meshes has been developed. Yet, few series have reported outcomes after abdominal wall repair (AWR) using such meshes. Permacol is an acellular porcine dermal collagen matrix with a cross-linked pattern. This study reports short- and long-term outcomes after AWR for incisional hernia using Permacol.Materials and methodsAll consecutive patients undergoing single-stage open AWR using Permacol mesh at eight university hospitals were included. Mortality, complication and hernia recurrence rates were assessed. Independent risk factors for complications and hernia recurrence were identified with logistic regression and Fine and Gray analysis, respectively.ResultsOverall, 250 patients underwent single-stage AWR with Permacol. Nearly 80% had a VHWG grade 3 or 4 defect. In-hospital mortality and complication rates were 4.8% (n = 12) and 61.6% (n = 154), respectively. Reintervention for complications was required for 74 patients (29.6%). Mesh explantation rate was 4% (n = 10). Independent risk factors for complications were smoking, defect size and VHWG grade. After a mean follow-up time of 16.8 months (± 18.1 months), 63 (25.2%) experienced hernia recurrence. One-, 2- and 3-year RFS were 90%, 74% and 57%, respectively. Previous AWR, mesh location and the need for reintervention were independent predictors of hernia recurrence.DiscussionSingle-stage AWR is feasible using Permacol. Mortality and complication rates are high due to patients’ comorbidities and the degree of contamination of the operative field. Given the observed recurrence rate, the benefit of biologics remains to be ascertained.

Background According to EULAR and OARSI guidelines, evidence is inconclusive for the symptomatic benefits of an unloader knee brace in medial knee osteoarthritis (OA). Objectives The objective of this multicenter randomised controlled trial (RCT) (ClinicalTrials Id. NCT02765685) was to compare the efficacy and safety of the ODRA brace, a distraction-rotation custom-made knee brace versus usual care over one year in medial knee OA. Methods Patients with symptomatic medial knee OA (VAS pain scores at rest >40/100 for the medial compartment) and Kellgren-Lawrence (KL) grade II-IV were randomised in two groups: brace group (ODRA +usual care) vs usual care alone (UCA). Patients were followed up every two months for one year. Usual care consisted of all the pharmacological and non-pharmacological treatments used for the management of knee OA. The primary end-point was the difference of VAS-pain between M0 and M12. Secondary end-points included patient global assessment of disease severity (PGA) on VAS,% of patients reaching the PASS (VAS-pain 20/100) thresholds at M12, KOOS scores, OA-specific quality of life questionnaire (OAKHQOL), as well as drug intake. Safety and compliance were evaluated by recording side effects and average knee brace duration of wear, respectively. Results Overall 120 patients (57% women) from 7 centres were included. Their characteristics were the following: mean age 63.6±11.4 years; BMI 29.6±5.5 kg/m2; OA duration 5.8±6 years; 52% KL III; 21% KL IV. The VAS pain decrease was statistically higher in the ODRA group (from 61.9±17.4 (M0) to 38.8±25.3 (M12) than in the UCA group (54.9±18.2 to 45.5±23.8) in the intent to treat bivariate and multivariate analyses (delta VAS-pain: 13.1±4.9, p Conclusions In this RCT, the use of the ODRA brace in addition to usual care was shown to be superior to usual care alone in reducing symptoms and improving quality of life of patients suffering from medial knee OA, with good compliance. Disclosure of Interest None declared

Background Our objective was to assess, through a qualitative, exploratory study, the thought processes of patients regarding the formulation of advance directives (AD) after a stay in the ICU. Methods The study was conducted from May to July 2016 using telephone interviews performed by four senior ICU physicians. Inclusion criteria were: patients discharged from ICU to home > 3 months earlier. Semi-directive interviews with patients focused on 5 main points surrounding AD. Results In total, among 159 eligible patients, data from 94 (59%) were available for analysis. Among all those interviewed, 83.5% had never heard of “advance directives”. Only 2% had executed AD before ICU admission, and 7% expressed a desire to prepare AD further to their ICU stay. Among the barriers to preparation of AD, lack of information was the main reason cited for not executing AD. Patients noted the following in their AD: withdrawal of life-support in case of vegetative/minimally conscious state or when there is no longer any hope, in case of uncontrollable pain, and if impossible to wean from mechanical ventilation. Conclusion The ideal time to engage patients in these discussions is most likely well before an acute health event occurs, although this warrants further investigation both before and after ICU admissions.

Infections are the most frequent complication after colorectal surgery. It has been suggested that adipose tissue metabolism could be related to the risk of post-operative infection, but this could be partially related to the body-mass index. The aim of this study was to look for a relation between adipocytokine levels and the risk of post-operative infection and its type.This prospective cohort study was conducted between March 2013 and March 2014 in two French teaching hospitals. Pre-operative plasma levels of adiponectin and leptin were measured in consecutive patients undergoing elective colorectal surgery. All infections in the 30 d following surgery were recorded.Among the 142 patients included, 29 (20.4%) presented a post-operative infection: 26 surgical site infections and three extra-abdominal infections. Adiponectin and leptin levels correlated weakly but substantially with the body mass index (rspearman=-0.26 and +0.31, respectively). While there was no substantial difference between patients with and those without post-operative infection for adiponectin, median pre-operative leptin was substantially greater in patients with post-operative infection (8.67 vs. 4.37 ng/mL, p=0.003). A substantial interaction was found between leptin and cancer. In patients operated on for cancer, the area under the receiver-operating characteristic (ROC) curve was lower than in patients with benign diseases (0.597 vs. 0.858, p=0.011). Similar results were observed for intra-abdominal infection and surgical site infection.Patients with greater levels of leptin before colorectal surgery have an increased risk of post-operative surgical infection. This effect is stronger in patients without cancer. Adiponectin levels are not related to the risk of infection in Western patients.

Inclusion in a randomized therapeutic trial represents an optimal therapeutic strategy.To determine the influence of demographic characteristics and deprivation on the enrolment of patients in digestive cancer clinical trials.Between 2004 and 2010, 4632 patients were recorded by the Burgundy Digestive Cancer Registry. According to a balancing score, the 136 patients included in a clinical trial were matched with 272 patients who met the eligibility criteria for trials. Deprivation was measured by the ecological European deprivation index. A conditional multivariate logistic regression was performed.Patients aged over 75 years were significantly less likely to be included in clinical trials than younger patients (odds ratio 0.33; [0.13-0.87]). Patients treated in private institutions were also less likely to be enrolled than those treated in public institutions (odds ratio 0.04; [0.01-0.16]; p0.001). A relationship between type of institution and the European deprivation index was observed (p=0.017). Deprived patients were less likely to be included in clinical trials when they were managed in private institutions (odds ratio 0.706; [0.524-0.952]; p=0.022). The European deprivation index had no impact when patients were managed in other institutions.The relationship between type of institution and deprivation underlines the necessity for improving patients' chance of being recruited in digestive cancer clinical trials.

IntroductionPrenatal care is recommended during pregnancy to improve neonatal and maternal outcomes. Women of lower socioeconomic status (SES) are less compliant to recommended prenatal care and suffer a higher risk of adverse perinatal outcomes. Several attempts to encourage optimal pregnancy follow-up have shown controversial results, particularly in high-income countries. Few studies have assessed financial incentives to encourage prenatal care, and none reported materno-fetal events as the primary outcome. Our study aims to determine whether financial incentives could improve pregnancy outcomes in women with low SES in a high-income country.Methods and analysisThis pragmatic cluster-randomised clinical trial includes pregnant women with the following criteria: (1) age above 18 years, (2) first pregnancy visit before 26 weeks of gestation and (3) belonging to a socioeconomically disadvantaged group. The intervention consists in offering financial incentives conditional on attending scheduled pregnancy follow-up consultations. Clusters are 2-month periods with random turnover across centres. A composite outcome of maternal and neonatal morbidity and mortality is the primary endpoint. Secondary endpoints include maternal or neonatal outcomes assessed separately, qualitative assessment of the perception of the intervention and cost-effectiveness analysis for which children will be followed to the end of their first year through the French health insurance database. The study started in June 2016, and based on an expected decrease in the primary endpoint from 18% to 14% in the intervention group, we plan to include 2000 women in each group.Ethics and disseminationEthics approval was first gained on 28 September 2014. An independent data security and monitoring committee has been established. Results of the main trial and each of the secondary analyses will be submitted for publication in a peer-reviewed journal.Trial registration numberNCT02402855; pre-results.

IF 3.988; International audience; BACKGROUND AND PURPOSE:Although there is growing and convincing evidence that socially deprived patients are at higher risk of stroke and worse outcomes, it remains controversial whether or not they suffer more severe stroke. This study aimed to evaluate the influence of social deprivation on initial clinical severity in patients with stroke.METHODS:A total of 1536 consecutive patients with an acute first-ever stroke (both ischaemic stroke and intracerebral hemorrhage) were prospectively enrolled from six French study centers. Stroke severity on admission was measured by the National Institutes of Health Stroke Scale score. Social deprivation was assessed at the individual level by the Evaluation de la Précarité et des Inégalités de santé dans les Centres d'Examen de Santé (EPICES) score, a validated multidimensional questionnaire, and several additional single socioeconomic indicators. Polytomous logistic regression analyses were performed to evaluate the association between social deprivation and stroke severity.RESULTS:In univariate analysis, the EPICES score (P = 0.039) and level of education (P = 0.018) were the only two socioeconomic variables associated with stroke severity. Multivariate analysis of the association between EPICES and National Institutes of Health Stroke Scale scores showed that more deprived patients presented a significantly higher risk of both mild and moderate/severe stroke (odds ratio for mild versus minor stroke, 1.39; 95% confidence interval, 1.06-1.84; odds ratio for moderate/severe versus minor stroke, 1.44; 95% confidence interval, 1.09-1.92). A non-significant trend towards a higher risk of both mild and moderate/severe stroke in less educated patients was observed.CONCLUSIONS:Social deprivation was associated with a more severe clinical presentation in patients with stroke. These findings may contribute to the worse outcome after stroke in deprived patients, and underline the need for strategies to reduce social inequalities for stroke.© 2017 EAN.