Objective: To describe the clinical spectrum of infective endocarditis in critically ill patients and assess the impact of neurologic complications on outcomes. Design: Prospective multicenter observational study conducted from April 2007 to October 2008. Setting: Thirty-three intensive care units in 23 university-affiliated and 10 general French hospitals. Patients: Two hundred twenty-five patients with definite IE were studied. Factors associated with neurologic complications and predictors of 3-month mortality were identified by logistic regression analysis. Functional outcomes of patients with neurologic complications were evaluated with the modified Rankin Scale. Interventions: None. Measurements and Main Results: Among 198 patients with definite left-sided infective endocarditis, 108 (55%) experienced at least one neurologic complication. These complications were ischemic stroke (n = 79), cerebral hemorrhage (n = 53), meningitis or meningeal reaction (n = 41), brain abscess (n = 14), and mycotic aneurysm (n = 10). Factors independently associated with neurologic complications were (subhazard ratio [95% confidence interval]): Staphylococcus aureus infective endocarditis (1.45 [1.02–2.05]), mitral valve infective endocarditis (1.54 [1.07–2.21]), and nonneurologic embolic events (1.51 [1.09–2.09]). In contrast, health care-associated infective endocarditis had a protective effect (0.46 [0.27–0.77]). Multivariate analysis identified three variables associated with 3-month mortality (odds ratio [95% confidence interval]): neurologic failure, as defined as a Glasgow Coma Scale <10 (7.41 [2.89–18.96]), S. aureus infective endocarditis (3.26 [1.53–6.94]), and severe comorbidities before admission as defined as a Charlson score >2 (3.16 [1.47–6.77]). Among the 106 patients with neurologic complications assessed at follow-up (3.9 [3–8.5] months), 31 (29%) had a modified Rankin Scale score ≤3 (ability to walk without assistance), nine (9%) a modified Rankin Scale score of 4 or 5 (severe disability), and 66 (62%) a modified Rankin Scale score of 6 (death). Conclusions: Neurologic events are the most frequent complications in infective endocarditis patients requiring intensive care unit admission. They contribute to a severe prognosis, leaving less than one-third of patients alive with functional independence. Neurologic failure at intensive care unit admission represents a major determinant of mortality regardless of the underlying neurologic complication.

Context: Deciphering the early processes occurring in adipose tissue during weight gain is a major issue for understanding the development of fat mass and obesity. Experimental overfeeding in humans is a unique situation to tackle these events. Objective: Our aim was to identify the pathways involved in sc adipose tissue remodeling during the initial phase of weight gain. Research Design and Methods: Forty-four healthy men were involved in an overfeeding protocol with a lipid-enriched diet (+760 kcal/d) for 2 months. Subcutaneous abdominal adipose tissue biopsies were taken for histology, transcriptomics, and Western blotting in the basal state, after 14 d, and at the end of the protocol. Results: Overfeeding significantly increased body weight (+2.5 kg) and fat mass. Reorganization of gene expression patterns occurred in adipose tissue with an up-regulation of numerous genes involved in lipid metabolism and storage, followed by clusters of genes related to angiogenesis and extracellular matrix remodeling. Histological examination showed increased microvascular density and connective tissue deposition after 56 d of overfeeding, with no changes in the number of macrophages or inflammatory cells. Inhibition of the canonical Wnt/β-catenin signaling pathway and induction of the renin-angiotensin system might be implicated in the remodeling of sc adipose tissue. Conclusions: We characterize the coordinated and time-dependent processes that occur in human adipose tissue during the early phase of weight gain in healthy subjects and identify pathways representing potential targets in pathologies of adipose development, including obesity.

Background: Non-invasive evaluation of left ventricular filling pressure has been scarcely studied in critically ill patients. Accordingly, we prospectively assessed the ability of transoesophageal echocardiography (TEE) Doppler to predict an invasive pulmonary artery occlusion pressure (PAOP) ≤ 18 mmHg in ventilated patients. Methods: During two consecutive 3-year periods, TEE Doppler parameters were compared to right heart catheterisation derived PAOP used as reference in 88 ventilated patients, haemodynamically stable and in sinus rhythm (age: 63 ± 14 years; simplified acute physiologic score (SAPS) II: 45 ± 12). During the initial period (protocol A), threshold values of pulsed-wave Doppler parameters to predict an invasive PAOP ≤ 18 mmHg were determined in 56 patients. Derived Doppler values were prospectively tested during the subsequent period (protocol B) in 32 patients. Results: In protocol A, Doppler parameters had similar area under the receiver operating characteristic (ROC) curve. In protocol B, mitral E/A ≤ 1.4, pulmonary vein S/D > 0.65 and systolic fraction > 44% best predicted an invasive PAOP ≤ 18 mmHg. Lateral E/E' ≤ 8.0 or E/Vp ≤ 1.7 predicted a PAOP ≤ 18 mmHg with a sensitivity of 83% and 80%, and a specificity of 88% and 100%, respectively. Areas under ROC curves of lateral E/E' and E/Vp were similar (0.91 ± 0.07 vs 0.92 ± 0.07: p = 0.53), and not significantly different from those of pulsed-wave Doppler indices. Conclusion: TEE accurately predicts invasive PAOP ≤ 18 mmHg in ventilated patients. This further increases its diagnostic value in patients with suspected acute lung injury/acute respiratory distress syndrome.

BACKGROUND: The use of extracorporeal life support (ECLS) in the trauma population remains controversial and has been reported only in small cohort studies. Recent ECLS technical advances have increased its use as an advanced critical care option in trauma. Given the degree of resource utilization, costs, and expertise required to provide ECLS support in trauma patients, we sought to perform a multi-institutional study to assess the indications and outcomes of ECLS in trauma. METHODS: A retrospective review of adult (≥16 years) trauma patients receiving ECLS support in the Extracorporeal Life Support Organization (ELSO) registry (1989–2016) was performed. Standardized data from the contributing ELSO centers includes patient demographics, diagnoses, and ECLS technique and procedures. Additionally, baseline characteristics, precannulation and postcannulation physiologic data, complications, and outcomes were recorded. Survival was categorized both by transition off ECLS support and survival to hospital discharge. RESULTS: Two hundred seventy-nine trauma patients were identified (0.92% of 30,273 adult ECLS patients). Extracorporeal life support increased significantly in the last 5 years (173 in 2011–2016, 62%) compared with 106 in the prior 18 years. Trauma patients were predominantly male (78%), with a mean age of 34.8 ± 15.4 years (range, 16–88 years). Thoracic injury was the most common diagnosis; acute respiratory distress syndrome was the most common indication. Extracorporeal life support was venovenous for respiratory failure (89%), VA for cardiac failure (7%), and VA for ECLS-assisted cardiopulmonary resuscitation (CPR) (E-CPR) (4%). Extracorporeal life support duration was 8.8 ± 9.5 days (longest 83 days), and was longer for respiratory support (9.3 ± 9.3 days) vs. cardiac support (4.1 ± 4.5 days) and E-CPR (6.5 ± 16.8 days). Overall survival from ECLS was 70% and survival to hospital discharge was 61% in the total cohort (63% respiratory, 50% cardiac, 25% E-CPR), similar to survival rates in other ELSO registry cohorts. More than 80% of patients had a reported complication during ECLS support. The most common complication was cardiovascular (51%) followed by a bleeding complication (29%). Multiple organ failure was the most common cause of death (15.4%). CONCLUSION: Data from the largest registry of critically ill trauma patients receiving ECLS support demonstrates reasonable survival. With growing experience and improved safety profile, trauma should not be considered a contraindication for ECLS. Further analysis of the ELSO registry regarding trauma-specific risk factors and ECLS-specific practices may identify best candidates and improve trauma ECLS outcomes. LEVEL OF EVIDENCE: Therapeutic study, level III.