Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome associated with COVID-19: An Emulated Target Trial Analysis.

RATIONALE: Whether COVID patients may benefit from extracorporeal membrane oxygenation (ECMO) compared with conventional invasive mechanical ventilation (IMV) remains unknown. OBJECTIVES: To estimate the effect of ECMO on 90-Day mortality vs IMV only Methods: Among 4,244 critically ill adult patients with COVID-19 included in a multicenter cohort study, we emulated a target trial comparing the treatment strategies of initiating ECMO vs. no ECMO within 7 days of IMV in patients with severe acute respiratory distress syndrome (PaO2/FiO2 <80 or PaCO2 ≥60 mmHg). We controlled for confounding using a multivariable Cox model based on predefined variables. MAIN RESULTS: 1,235 patients met the full eligibility criteria for the emulated trial, among whom 164 patients initiated ECMO. The ECMO strategy had a higher survival probability at Day-7 from the onset of eligibility criteria (87% vs 83%, risk difference: 4%, 95% CI 0;9%) which decreased during follow-up (survival at Day-90: 63% vs 65%, risk difference: -2%, 95% CI -10;5%). However, ECMO was associated with higher survival when performed in high-volume ECMO centers or in regions where a specific ECMO network organization was set up to handle high demand, and when initiated within the first 4 days of MV and in profoundly hypoxemic patients. CONCLUSIONS: In an emulated trial based on a nationwide COVID-19 cohort, we found differential survival over time of an ECMO compared with a no-ECMO strategy. However, ECMO was consistently associated with better outcomes when performed in high-volume centers and in regions with ECMO capacities specifically organized to handle high demand. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Devenir à long terme des patients admis en réanimation neurochirurgicale et victimes d' un hématome intracérébral d' origine primaire ou par malformation arterioveineuse

En dépit des progrès de leur prise en charge, le pronostic fonctionnel des patients victimes d'hématomes intracérébraux reste médiocre. Peu d'études tiennent compte des conséquences sociales à long terme. Nous comparons l'évolution de patients victimes d'hématomes d'origine primaire ou par rupture de malformation artérioveineuse, admis en réanimation neurochirurgicale, deux ans après l'accident, et recherchons des facteurs de risque de mauvaise évolution. Etude rétrospective monocentrique (Pitié-Salpêtrière) de Janvier 2005 à Décembre 2007. Recueil de l'ensemble des données cliniques, biologiques et radiologiques du séjour en réanimation neurochirurgicale. Entretien téléphonique deux ans après l'accident et évaluation du devenir fonctionnel. 40 patients admis pour hématome d'origine primaire, 23 pour hématome par rupture de malformation artérioveineuse, 19 patients perdus de vue. 18 % des patients sont décédés. 45 % ont un GOSE >= 5, sans différence entre les deux groupes étiologiques. 86 % des patients présentent au moins un trouble neuropsychologique. Les patients victimes de rupture de malformation artérioveineuse présentent plus de difficultés professionnelles (85 % versus 43 %). Seule l'instauration d'une ventilation mécanique au cours de la prise en charge apparaît comme un facteur de risque d'évolution défavorable. L'intensité des soins prodigués en réanimation neurochirurgicale améliore le pronostic des patients victimes d'hématome intracérébral primaire ou par rupture de malformation artérioveineuse. Un nombre important garde toutefois des séquelles neuropsychologiques. Une réflexion doit s'engager sur la qualité des scores pronostiques disponibles, et le bénéfice réel apporté aux patients.PARIS6-Bibl.Pitié-Salpêtrie (751132101) / SudocSudocFranceF

Spectroscopie de nanosondes hybrides à cœur métallique

ORSAY-PARIS 11-BU Sciences (914712101) / SudocSudocFranceF

Photoluminescence spectra and quantum yields of gold nanosphere monomers and dimers in aqueous suspension

International audienceThe intrinsic one-photon excited photoluminescence (PL) of dimers and monomers of gold spheres suspended in water was studied by combining photon time-of-flight spectroscopy (PTOFS) and light scattering fluctuation correlation spectroscopy (LS-FCS). The samples are obtained by precisely controlling the dimerization of aqueous colloidal systems based on 50 and 80 nm gold nanospheres. The combination of PTOFS and LS-FCS enables the separate spectroscopic study of monomers and dimers even though they exist as a mixture in the samples. PL emission spectra and diffusional dynamics are obtained simultaneously through measurement at the single particle level. The PL spectra resemble the light scattering spectra, indicating the plasmon-assisted character of the photoluminescence process. We determine the intrinsic PL quantum yields of the dimers and the monomers. It is often not possible to measure such very low quantum yields in solution using conventional techniques, and we show here that PTOFS provides access to this information. The quantum yield of the dimers was found to be of same order of magnitude as that of the monomers, of the order of 10 À6 , which indicates that the interparticle 'electromagnetic hot-spots' do not play a major role in the luminescence emission mechanism in such plasmonic molecules

Treating Acute Severe Eosinophilic Asthma with IL-5 Inhibitors in ICU

International audienceINTRODUCTION: About 10% of the 300 million people worldwide who suffer from asthma have a severe disease that is uncontrolled despite treatment with inhaled corticosteroids and long-acting beta agonists. The eosinophilic inflammation pathway in the respiratory tract and blood is involved and interleukin-5 (IL-5) has recently been identified as a major promotor of this pathway. The anti-IL-5 antibodies reduce the incidence of exacerbation and allowed steroid sparing in severe asthma patients but only two case reports have been published on their use in critical care. Case Presentation. This report describes the extraordinary clinical improvement of a young patient with steroid-refractory eosinophilic acute severe asthma who required mechanical ventilation, VV-ECMO followed by treatment with mepolizumab. The salient point in this case is the use of an anti-IL-5 monoclonal antibody for a critically ill patient whose condition was deteriorating despite mechanical ventilation and VV-ECMO. The usual steroid treatment failed to control the increase in blood eosinophils or his bronchial inflammation and constriction. CONCLUSION: Anti-IL-5 antibodies are now a standard treatment for severe eosinophilic asthma that can also be useful in an emergency to treat steroid-refractory eosinophilic acute severe asthma

Impact of early low-calorie low-protein versus standard-calorie standard-protein feeding on outcomes of ventilated adults with shock: design and conduct of a randomised, controlled, multicentre, open-label, parallel-group trial (NUTRIREA-3)

International audienceInternational guidelines include early nutritional support (≤48 hour after admission), 20–25 kcal/kg/day, and 1.2–2 g/kg/day protein at the acute phase of critical illness. Recent data challenge the appropriateness of providing standard amounts of calories and protein during acute critical illness. Restricting calorie and protein intakes seemed beneficial, suggesting a role for metabolic pathways such as autophagy, a potential key mechanism in safeguarding cellular integrity, notably in the muscle, during critical illness. However, the optimal calorie and protein supply at the acute phase of severe critical illness remains unknown. NUTRIREA-3 will be the first trial to compare standard calorie and protein feeding complying with guidelines to low-calorie low-protein feeding. We hypothesised that nutritional support with calorie and protein restriction during acute critical illness decreased day 90 mortality and/or dependency on intensive care unit (ICU) management in mechanically ventilated patients receiving vasoactive amine therapy for shock, compared with standard calorie and protein targets. Methods and analysis NUTRIREA-3 is a randomised, controlled, multicentre, open-label trial comparing two parallel groups of patients receiving invasive mechanical ventilation and vasoactive amine therapy for shock and given early nutritional support according to one of two strategies: early calorie-protein restriction (6 kcal/kg/day-0.2–0.4 g/kg/day) or standard calorie-protein targets (25 kcal/kg/day, 1.0–1.3 g/kg/day) at the acute phase defined as the first 7 days in the ICU. We will include 3044 patients in 61 French ICUs. Two primary end-points will be evaluated: day 90 mortality and time to ICU discharge readiness. The trial will be considered positive if significant between-group differences are found for one or both alternative primary endpoints. Secondary outcomes include hospital-acquired infections and nutritional, clinical and functional outcomes. Ethics and dissemination The NUTRIREA-3 study has been approved by the appropriate ethics committee. Patients are included after informed consent. Results will be submitted for publication in peer-reviewed journals. Trial registration number NCT03573739

Impact of early low-calorie low-protein versus standard-calorie standard-protein feeding on outcomes of ventilated adults with shock: design and conduct of a randomised, controlled, multicentre, open-label, parallel-group trial (NUTRIREA-3)

Introduction International guidelines include early nutritional support (≤48 hour after admission), 20–25 kcal/kg/day, and 1.2–2 g/kg/day protein at the acute phase of critical illness. Recent data challenge the appropriateness of providing standard amounts of calories and protein during acute critical illness. Restricting calorie and protein intakes seemed beneficial, suggesting a role for metabolic pathways such as autophagy, a potential key mechanism in safeguarding cellular integrity, notably in the muscle, during critical illness. However, the optimal calorie and protein supply at the acute phase of severe critical illness remains unknown. NUTRIREA-3 will be the first trial to compare standard calorie and protein feeding complying with guidelines to low-calorie low-protein feeding. We hypothesised that nutritional support with calorie and protein restriction during acute critical illness decreased day 90 mortality and/or dependency on intensive care unit (ICU) management in mechanically ventilated patients receiving vasoactive amine therapy for shock, compared with standard calorie and protein targets.Methods and analysis NUTRIREA-3 is a randomised, controlled, multicentre, open-label trial comparing two parallel groups of patients receiving invasive mechanical ventilation and vasoactive amine therapy for shock and given early nutritional support according to one of two strategies: early calorie-protein restriction (6 kcal/kg/day-0.2–0.4 g/kg/day) or standard calorie-protein targets (25 kcal/kg/day, 1.0–1.3 g/kg/day) at the acute phase defined as the first 7 days in the ICU. We will include 3044 patients in 61 French ICUs. Two primary end-points will be evaluated: day 90 mortality and time to ICU discharge readiness. The trial will be considered positive if significant between-group differences are found for one or both alternative primary endpoints. Secondary outcomes include hospital-acquired infections and nutritional, clinical and functional outcomes.Ethics and dissemination The NUTRIREA-3 study has been approved by the appropriate ethics committee. Patients are included after informed consent. Results will be submitted for publication in peer-reviewed journals.Trial registration number NCT03573739