A tailored multicomponent program to reduce discomfort in critically ill patients: a cluster-randomized controlled trial

Purpose

Critically ill patients are exposed to stressful conditions and experience several discomforts. The primary objective was to assess whether a tailored multicomponent program is effective for reducing self-perceived discomfort.

Methods

In a cluster-randomized two-arm parallel trial, 34 French adult intensive care units (ICUs) without planned interventions to reduce discomfort were randomized, 17 to the arm including a 6-month period of program implementation followed by a 6-month period without the program (experimental group), and 17 to the arm with an inversed sequence (control group). The tailored multicomponent program consisted of assessment of ICU-related self-perceived discomforts, immediate and monthly feedback to healthcare teams, and site-specific tailored interventions. The primary outcome was the overall discomfort score derived from the 16-item IPREA questionnaire (0, minimal, 100, maximal overall discomfort) and the secondary outcomes were the discomfort scores of each IPREA item. IPREA was administered on the day of ICU discharge with a considered timeframe from the ICU admission until ICU discharge.

Results

During a 1-month assessment period, 398 and 360 patients were included in the experimental group and the control group, respectively. The difference (experimental minus control) of the overall discomfort score between groups was ? 7.00 (95% CI ? 9.89 to ? 4.11, p < 0.001). After adjustment (age, gender, ICU duration, mechanical ventilation duration, and type of admission), the program effect was still positive for the overall discomfort score (difference ? 6.35, SE 1.23, p < 0.001) and for 12 out of 16 items.

Conclusions

This tailored multicomponent program decreased self-perceived discomfort in adult critically ill patients. Trial Registration: Clinicaltrials.gov Identifier NCT02442934.

     

An unusual complication of intra-articular injections of corticosteroids: Tachon syndrome. Two case reports.

Local injections of corticosteroids can, in very rare cases, be complicated by Tachon syndrome-intense lumbar and/or dorsal and/or thoracic pain a few minutes after the injection, with rapid regression of the pain. Passing the drug into a vein through a nick made during the procedure could explain the pathophysiology of this disorder. We report two good cases illustrating the typical symptoms of this distressful syndrome. Diagnosis of Tachon syndrome is made by elimination of the usual medical and surgical causes, and physicians performing local injections should be aware of this phenomenon. The patient needs to be reassured of the temporal nature of the syndrome.     

Supervised or unsupervised exercise for the treatment of hip and knee osteoarthritis. Clinical practice recommendations.

OBJECTIVES: To develop clinical practice guidelines concerning supervised or unsupervised kinesiotherapy for treating lower-limb osteoarthritis (OA). METHOD: The SOFMER (French Physical Medicine and Rehabilitation Society) methodology, associating systematic literature review, collection of everyday clinical practice, and external review by a multidisciplinary expert panel, was used to develop guidelines. RESULTS-CONCLUSION: Physical exercise is a part of the treatment of lower-limb OA. An educational pre-program is recommended to inform the patient about the ease and effectiveness of the physical exercise. Use of the SOFMER methodology led to recommending a program of initial physical exercise supervised by a physiotherapist, then an unsupervised program at home with compliance. The type, intensity, and frequency of the exercises must be adapted to each patient. Complementary randomized controlled studies are necessary to characterize the best exercises and their intensity and frequency. The OA location and gravity, functional need, and characteristics of patients will be useful in future studies.     

Establishing recommendations for physical medicine and rehabilitation: the SOFMER methodology.

OBJECTIVE: The development of a rigorous methodology based on published results of clinical trials, evaluation of daily practice in France and multidisciplinary expert opinion to elaborate recommendations for rehabilitation interventions. METHODS AND RESULTS: The following describes the methodology of SOFMER (Société Fran?aise de Médecine Physique et de Réadaptation [French Society of Physical Medicine and Rehabilitation]) for developing recommendations for rehabilitation interventions. The test case was developing recommendations for rehabilitation in hip or knee osteoarthritis (OA) and hip or knee arthroplasty. Physicians in rehabilitation, orthopedic surgery and rheumatology identified, synthesized, and analyzed data from the literature by use of the usual French system of grading trials (the French Agency for Accreditation and Evaluation in Healthcare [ANAES] scale). The data were published results of comparative controlled studies such as randomized controlled trials, controlled clinical trials, cohort studies, case control studies, reviews of clinical trials, and case series, as well as uncontrolled cohort studies. The resulting recommendations were presented to the three annual French national congresses of rehabilitation, rheumatology, and orthopedic surgery for comment and for adapting to French professional practice. Finally, a panel of multidisciplinary experts (physicians in physical medicine and rehabilitation, rheumatologists, orthopedic surgeons, general practitioners, physical therapists, social workers, podologists, occupational therapists, nurses, and patients) validated the recommendations. CONCLUSION: The SOFMER methodology could be an interesting tool for use in developing recommendations elaborated by all the concerned medical and surgical specialists in the wide domain of rehabilitation.     

Monolayer anulus fibrosus cell cultures in a mechanically active environment: local culture condition adaptations and cell phenotype study

Intervertebral disc cells can be cultured in vitro. Several culturing systems in a mechanically active environment have been developed to study the relationship between mechanical stimulations and biochemical events. The aim of this study was to assess the phenotype of rabbit intervertebral disc cells from the anulus fibrosus (AF) region cultured on flexible substrate before and after application of cyclic tensile stretch (CTS) and to control culture conditions during application of CTS. CTS was applied with a pressure-operated instrument, inducing the deformation of flexible-bottomed culture plates (Flexercell) at 20% and 5% stretch, at a frequency of 1 Hz, during 30 minutes to 24 hours. A significant decrease in culture medium volume and temperature was observed (52% and 2.1 degrees C at 20% stretch and 24 hours' application of CTS). These phenomena were inhibited by adding culture medium around culture wells and by a culture medium temperature control system. Like AF cells cultured in plastic wells, AF cells cultured on flexible substrate expressed collagen type II, but collagen type I mRNA was not detected. In both culture conditions, neosynthesized proteoglycans had the same aggregating properties. CTS at 20% stretch during 12 hours did not induce cell detachment from the substrate and did not modify aggregating properties of neosynthesized proteoglycans; AF cells continued to express collagen type II but not collagen type I mRNA. In conclusion, the Flexercell system appears to be appropriate for studying, at the cellular level, the metabolic responses to CTS.     

两种荧光显微成像系统亚细胞定位的对比

目的:应用高分辨率荧光显微成像系统采集细胞器探针图像,并与激光共聚焦显微成像系统进行对比。方法:实验于2003-05/2004-01在解放军总医院完成。①实验材料:鼠肺毛细血管内皮细胞株(1H11)由上海复旦张江生物公司提供;荧光探针Rhodamine-123,Lucifer Yellow,DiOC6[3],BODIPY(美国Sigma公司)。②细胞培养及荧光探针染色:细胞培养采用含体积分数为0.2胎牛血清的低糖DMEM培养基,密度5×107L-1。选择Rhodamine-123作为细胞线粒体特异性荧光探针,选择DiOC6[3]作为细胞内质网特异性荧光探针,选择BODIPY作为细胞高尔基体特异性荧光探针,选择Lucifer Yellow作为细胞溶酶体探针。前3个探针在完全避光条件下与培养的细胞共同孵育0.5h,后者则共同孵育15h。③高分辨率荧光成像系统的图像采集:线粒体荧光图像采集,选取经Rhodamine-123共孵育完成的细胞,选择激发滤色镜为BP460-490,吸收滤色镜为BA515,分光镜为DM500,另加一绿通道液晶滤光片,激发出Rhodamine-123的荧光。电荷耦合器件采集图像并送入计算机。重复上述步骤,采用DiOC6[3]标记内质网,BODIPY标记高尔基体,Lucifer Yellow标记细胞溶酶体,激发条件同Rhodamine-123。分别采集同一视野靶细胞DiOC6[3]、BODIPY或Lucifer Yellow的荧光图像,完成全部图像采集并储存在计算机中。④激光共聚焦显微成像系统的图像采集:选择经4种探针染色的靶细胞,使用氩离子激光器在488nm激发Rhodamine-123,Rhodamine-123荧光通过配置有530/60-G发射滤光片的通道1探测。重复上述步骤,在488nm激发DiOC6[3]和BODIPY,在457nm激发Lucifer yellow,3种荧光均由通道1探测,后2个探针的发射滤光片的配置为515/30-G,DiOC6[3]选择530/60-G。由光电倍增管接收信号并传输入计算机成像。结果:①高分辨率荧光成像系统所采集图像,靶细胞中由荧光探针Rhodamine-123染色的线粒体呈多个典型的小棒状或卵圆状,聚集在核周;Lucifer yellow染色的溶酶体呈多个非对称球型,在胞浆内随机分布,颗粒尺寸通常大于线粒体;荧光探针DiOC6[3]着色的内质网占据胞浆的很大空间,以囊状聚集为特征;BODIPY特异性地结合在高尔基体上,荧光图像显示围绕在细胞核周围呈条索状。②与高分辨率荧光成像系统比较,激光共聚焦显微成像系统所采集的图像其荧光强度基本相同,但分辨率低、细节显示模糊、胞浆中细胞器的准确分布信息和形态特征显示效果欠佳。结论:两种荧光显微成像系统均可采集到细胞器探针的荧光图像。但高分辨率荧光成像系统采集的荧光图像具有细节清晰、分辨度高、准确显示胞浆中细胞器的分布信息和形态特征等优点。     

Cardiac toxicity of catecholamines. Report of two cases

INTRODUCTION: The role of catecholamines in the cardiac expression of pheochromocytoma is well-known. The physiopathology of the syndrome of Tako-tsubo remains more unclear. EXEGESIS: We describe 2 clinical cases of acute coronary syndrome with left ventricular dysfunction and no coronary artery stenosis. The first, a syndrome of Tako-tsubo, also known as transient left ventricular apical ballooning syndrome, is characterized by transient wall-motion in the absence of obstructive epicardial coronary disease. The second is a pheochromocytoma with myocardial suffering during hypertension crisis. Through the similarities of these 2 observations, we discuss the physiopathological assumptions to explain the syndrome of Tako-tsubo by underlining the essential place of the catecholamine hypersecretion. CONCLUSION: Syndrome of Tako-tsubo and pheochromocytoma are 2 distinct clinical entities. The link between these 2 affections is probably the pathogenic role in cardiac toxicity with the catecholamines.     

Is It possible to recognize pulmonary infarction on multisection CT images?

PURPOSE: To retrospectively determine sensitivity and specificity of four findings for distinguishing pulmonary infarction from other causes of peripheral pulmonary consolidations on multidetector computed tomographic (CT) images, with other CT and clinical findings as reference. MATERIALS AND METHODS: Institutional review board approved the study and waived informed consent. Three independent radiologists blindly analyzed selected multisection CT images of 50 pulmonary infarctions-not showing direct arterial signs of pulmonary embolism-and 100 peripheral consolidations of other origins. Readers analyzed four findings: triangular shape, vessel sign (defined as presence of an enlarged vessel at the apex of consolidation), central lucencies, and air bronchograms. Interobserver agreement; frequency on CT images with and without infarct; and sensitivity, specificity, and positive likelihood ratio (LR) for diagnosis of pulmonary infarction were assessed for each finding. RESULTS: One hundred fifty peripheral consolidations were analyzed in 134 (75 men, 59 women) patients (mean age, 55.9 years+/-17.4 [standard deviation] vs 54.7+/-19.9; P=.71). Interobserver agreement was good for central lucencies and air bronchograms and poor to moderate for the other two findings (kappa<0.61). Compared with CT images without infarct, CT images with infarct had a higher frequency of vessel sign (32% [16 of 50] vs 11% [11 of 100], P=.029) and central lucencies (46% [23 of 50] vs 2% [two of 100], P<.001) and a lower frequency of air bronchograms (8% [four of 50] vs 40% [40 of 100], P=.003). Frequency of triangular shape was similar in both groups (52% [26 of 50] vs 40% [40 of 100], P=.17). Positive LR was 23.0 for central lucencies, 2.9 for vessel sign, 1.3 for triangular shape, and 0.2 for air bronchograms. Presence of central lucencies had 98% specificity and 46% sensitivity for pulmonary infarction. When the vessel sign and negative air bronchogram were combined with central lucencies, specificity increased to 99% but sensitivity decreased to 14%. CONCLUSION: Central lucencies in peripheral consolidations are highly suggestive of pulmonary infarction.