Objectives: Thrombocytopenia is a common, multifactorial, finding in ICU. Hemophagocytosis is one of the main explanatory mechanisms, possibly integrated into hemophagocytic lymphohistiocytosis syndrome, of infectious origin in the majority of cases in ICU. The hemophagocytic lymphohistiocytosis is probably underdiagnosed in the ICU, although it is associated with dramatic outcomes. The main objectives of this work were to identify the frequency of secondary hemophagocytic lymphohistiocytosis, and the main prognostic factors for mortality. Design/Setting: We conducted a retrospective observational study in all adult patients admitted with suspected or diagnosed hemophagocytic lymphohistiocytosis, between January 1, 2000, and August 22, 2012. Patients: A total of 106 patients (42%) had significant hemophagocytosis on bone marrow examination, performed for exploration of thrombocytopenia, bicytopenia, or pancytopenia. Measurements and Main Results: The median age was 56 (45–68) and the median Simplified Acute Physiology Score 2 was 55 (38–68). The main reason for ICU admission was hemodynamic instability (58%), predominantly related to sepsis (45% cases). The main precipitating factor found was a bacterial infection in 81 of 106 patients (76%), including 32 (30%) with Escherichia coli infection. Forty six of 106 patients (43%) died in the ICU. They were significantly older, had higher Simplified Acute Physiology Score 2, plasma lactate deshydrogenase bilirubin, and serum ferritin. The fibrinogen and the percentage of megakaryocytes were significantly lower in nonsurvivors when compared with survivors. In multivariate analysis, only serum ferritin significantly predicted death related to hemophagocytosis. A serum ferritin greater than 2,000 μg/L predicted death with a sensitivity of 71% and a specificity of 76%. A decreased percentage of megakaryocytes also predicted patient death in the ICU. Conclusions: Hemophagocytosis is common in thrombocytopenic patients with sepsis, frequently included in a postinfectious hemophagocytic lymphohistiocytosis setting. Our study reveals that ferritin could be a reliable prognostic marker in these patients, and hold particular interest in discussing a specific treatment for hemophagocytic lymphohistiocytosis.

Despite the extensive use of high-flow nasal cannula (HFNC) therapy in intensive care units (ICU) for acute respiratory failure (ARF), its daily clinical practice has not been assessed. We designed a regional survey in ICUs in North-west France to evaluate ICU physicians’ clinical practice with HFNC. We sent an observational survey to ICU physicians from 34 French ICUs over a 6-month period in 2016–2017. The survey included questions regarding the indications and expected efficiency of HFNC, practical aspects of use (initiation, weaning) and satisfaction. Comparisons between junior and senior ICU physicians were performed using a Fischer exact test. Among the 235 ICU physicians contacted, 137 responded (58.3%) all of whom regularly used HFNC. Hypoxemic ARF was considered a good indication for HFNC by all 137, but only 30% expected HFNC success (i.e., avoiding intubation in at least 60% of cases). Among hypoxemic indications, 30% of juniors considered acute pulmonary edema a good indication versus 74% of seniors (p < 0.0001). Hypercapnic ARF was considered a good indication by 33% with only 2% expecting HFNC success. A need for conventional oxygen therapy ≥ 6 L/min justified HFNC therapy for 40% and ≥ 9 L/min for 39% of responders. 58% of ICU physicians started HFNC therapy with a FiO2 ≥ 50% and 28% with a gas flow ≥ 50 L/min. Practices for HFNC weaning were heterogeneous: 48% considered a FiO2 ≤ 30%; whereas, 30% considered a FiO2 ≤ 30% with a high flow ≤ 20 L/min. Criteria for HFNC failure (i.e., need for intubation) were ventilatory pauses or arrest (97%), persistent hypoxemia (95%), respiratory acidosis (81%), worsening of breathing (95%, 100% of seniors and 86% of juniors, p = 0.003), bronchial congestion (75%) and circulatory failure (61%, 72% of seniors and 44% of juniors, p = 0.007). HFNC is used by ICU physicians in many situations of ARF, despite their relatively low expectations of success, especially in cases of hypercapnia. Clinical practices appear somewhat heterogeneous. Despite the physiological benefit of HFNC, further prospective observational studies are still required on HFNC outcomes and daily practices.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: The WhatsApp® (WA) smartphone application is the most widely used instant messaging application in the world. Recent studies report the use of WA for educational purposes but there is no prospective study comparing WA's pedagogical effectiveness to any other teaching modality. The goal of this study was to evaluate this cross-platform messaging as a pedagogic tool for the teaching of residents. Objective: The main objective of this study was to evaluate the impact of WA on clinical reasoning. Methods: Prospective, randomized, multicenter study conducted among first and second year anesthesiology residents (online recruitment) from four university hospitals in France. Residents were randomized in two groups of online teaching (WA and control). The WA group benefited from daily delivery on the WA application of teaching documents and a weekly clinical case supervised by a senior physician. In the control group, residents had access to the same documents via a traditional computer e-learning platform. Medical reasoning was self-assessed online by script concordance test (SCT; primary parameter) and medical knowledge by multiple choice questions (MCQ). The residents completed an online satisfaction questionnaire. Results: In this study, 62 residents were randomized (32 in WA group, 30 in control group), 22 residents in each group answered the online final evaluation. We found a difference between WA and control groups for SCT (60 ± 9 % vs. 68 ± 11 %, respectively; P = .006) but no difference for MCQ (18 ± 4 /30 vs. 16 ± 4 /30, respectively; P = .22). Concerning satisfaction, there was a better global satisfaction rate in the WA group compared to control (9 ± 1 /10 vs. 8 ± 2 /10; P = .049). Conclusions: In this study, the use of WA compared to traditional e-learning for resident teaching was associated with worse clinical reasoning despite better global appreciation. The use of WA probably contributes to the dispersion of attention linked to the use of the smartphone. The impact of smartphones on clinical reasoning should be further studied.