Rapid response system for critically ill patients with haematological malignancies: A pre- and post-intervention study.

BACKGROUND: This study aimed to determine whether implementing a rapid response system (RRS) is associated with improved short-term outcomes in critically ill patients with haematological malignancies. METHODS: Our monocentric pre- versus post-intervention study was conducted between January 2012 and April 2020. RRS was activated at early signs of haemodynamic or respiratory failure. The primary outcome was the reduction in Sequential Organ Failure Assessment (SOFA) score on Day 3 after intensive care unit (ICU) admission. Secondary outcomes included time to ICU admission and mortality. RESULTS: A total of 209 patients with a median age of 59 years were enrolled (108 in the pre-intervention period and 101 in the post-intervention period). 22% of them had received an allogeneic transplant. The post-intervention period was associated with a shorter time to ICU admission (195 vs. 390 min, p < .001), a more frequent favourable trend in SOFA score (57% vs. 42%, adjusted odds ratio, 2.02, 95% confidence interval, 1.09 to 3.76), no significant changes in ICU (22% vs. 26%, p = .48) and 1-year (62% vs. 58%, p = .62) mortality rates. CONCLUSION: Detection of early organ failure and activation of an RRS was associated with faster ICU admission and lower SOFA scores on Day 3 of admission in critically ill patients with haematological malignancies.

ICU survival and need of renal replacement therapy with respect to AKI duration in critically ill patients.

BACKGROUND: Transient and persistent acute kidney injury (AKI) could share similar physiopathological mechanisms. The objective of our study was to assess prognostic impact of AKI duration on ICU mortality. DESIGN: Retrospective analysis of a prospective database via cause-specific model, with 28-day ICU mortality as primary end point, considering discharge alive as a competing event and taking into account time-dependent nature of renal recovery. Renal recovery was defined as a decrease of at least one KDIGO class compared to the previous day. SETTING: 23 French ICUs. PATIENTS: Patients of a French multicentric observational cohort were included if they suffered from AKI at ICU admission between 1996 and 2015. INTERVENTION: None. RESULTS: A total of 5242 patients were included. Initial severity according to KDIGO creatinine definition was AKI stage 1 for 2458 patients (46.89%), AKI stage 2 for 1181 (22.53%) and AKI stage 3 for 1603 (30.58%). Crude 28-day ICU mortality according to AKI severity was 22.74% (n = 559), 27.69% (n = 327) and 26.26% (n = 421), respectively. Renal recovery was experienced by 3085 patients (58.85%), and its rate was significantly different between AKI severity stages (P < 0.01). Twenty-eight-day ICU mortality was independently lower in patients experiencing renal recovery [CSHR 0.54 (95% CI 0.46-0.63), P < 0.01]. Lastly, RRT requirement was strongly associated with persistent AKI whichever threshold was chosen between day 2 and 7 to delineate transient from persistent AKI. CONCLUSIONS: Short-term renal recovery, according to several definitions, was independently associated with higher mortality and RRT requirement. Moreover, distinction between transient and persistent AKI is consequently a clinically relevant surrogate outcome variable for diagnostic testing in critically ill patients.

Spontaneous confabulations and behavioral and cognitive dysexecutive syndrome.

We have examined and diagnosed confabulation in a 20-year-old woman who had suffered severe traumatic brain injury (TBI) when she was 12. Spontaneous confabulations were associated with dysexecutive behavior involving perseveration and impulsiveness. The patient was amnesic during neuropsychological tests but did not present intrusion, confabulation or false recognition. She could evoke self-constitutive autobiographical events accurately and without fantasizing. The only difference between her false and true recollections is that the patient could never envision herself as an actor in a scene involving confabulation. She succeeded, albeit slowly, in carrying out the classic executive tests: Stroop, Trail Making A and B and Wisconsin Card Sorting (WCST). She showed particularly slow reaction time and was impulsive and hurried in her performance of the D2 attention test, the errands (Martin) test and the chocolate cake test. Her working memory was significantly impaired. A peculiar inability to inhibit the generation of fictional constructions may reflect a problem in control of short-term memory. Diagnosis of the confabulation phenomenon has had three clinical consequences: 1) information has been given to the patient, her family and other people close to her; 2) reeducation by means of voluntary memory control prior to speaking has been proposed; 3) reporting on the case has been improved.

[Ecologic evaluation in the cognitive assessment of brain injury patients: generation and execution of script]. / Apport de l'évaluation de la cognition dans une tâche de vie quotidienne chez des patients cérébrolésés: génération et exécution d'un script de cuisine.

OBJECTIVE: Assessment of executive functions in an everyday life activity, evaluating brain injury subjects with script generation and execution tasks. MATERIALS AND METHODS: We compared a script generation task to a script execution task, whereby subjects had to make a cooked dish. Two grids were used for the quotation, qualitative and quantitative, as well as the calculation of an anosognosis score. We checked whether the execution task was more sensitive to a dysexecutive disorder than the script generation task and compared the scores obtained in this evaluation with those from classical frontal tests. Twelve subjects with brain injury 6 years+/-4.79 ago and 12 healthy control subjects were tested. The subjects carried out a script generation task whereby they had to explain the necessary stages to make a chocolate cake. They also had to do a script execution task corresponding to the cake making. RESULTS: The 2 quotation grids were operational and complementary. The quantitative grid is more sensitive to a dysexecutive disorder. The brain injury subjects made more errors in the execution task. CONCLUSION: It is important to evaluate the executive functions of subjects with brain injury in everyday life tasks, not just in psychometric or script-generation tests. Indeed the ecological realization of a very simple task can reveal executive function difficulties such as the planning or the sequencing of actions, which are under-evaluated in laboratory tests.

[Self-evaluation of physical, cognitive and mood symptoms in a cohort of traumatic and vascular brain injury patients participating in social and neuropsychological remediation programmes]. / Auto-évaluation de la gêne physique, cognitive et thymique de sujets cérébrolésés. Effet d'une prise en charge spécifique.

INTRODUCTION: We studied 23 vascular or traumatic head injury subjects, five years after their injury. METHODS: Neuropsychological testing included language tests, memory performance, frontal lobe tests and standard tests of intelligence (QI). Behavior was evaluated with the neuropsychiatric interview (NPI). Using an analogic visual scale, subjects performed a self-evaluation of their memory, language, attention, physical and thymic complaints. RESULTS: Neuropsychological assessment was heterogeneous but seemed to show severe impairment. Mean NPI score was 31.4: 91 percent of patients showed depression or anxiety and 78 percent of them showed irritability. Mean memory and thymic complaints were scored 6 on the analogic visual scale. Thymic complaint was not correlated with neuropsychological tests but with physical complaints. Thymic complaint was correlated with NPI score. Language complaint was correlated with VIQ, attentional complaint was correlated with PIQ, memory complaint with memory tests. In a second part, we studied 21 patients again 6 months later and 14 patients 1 year later. Mean complaints were scored over 5 after 6 months and over 4 after 1 year. With neuropsychological remediation and social activities, memory complaints improved significantly after 6 months and attentional and thymic complaints after 1 year. CONCLUSION: Using of analogical visual scales appears to be feasible: patients were able to evaluate their difficulties. This could be useful to elaborate remediation programs and evaluate outcome.

Patterns of attentional impairment following closed head injury: a collaborative European study.

A comprehensive assessment of both selective (focused attention, divided attention) and intensive (alertness and vigilance) attentional processes was performed on 106 patients with closed head injury using a computerised battery for the evaluation of attention. All patients were tested at least five months after their accident. A high percentage of patients were pathological in tests mapping the selective components of attention while only a minority were impaired on tests mapping the intensive components of attention. Three different subgroups of patients with consistent performance patterns were evidenced. The psychometric characteristics of the battery and its possible clinical usefulness are discussed.

[Rehabilitation of memory: strategies, indications and limits]. / Rééducation de mémoire: stratégies, indications et limites.

The rehabilitation of memory must be defined in terms of patient selection, therapist support and techniques as accurately as for language therapy. Three objectives can be offered for organic amnesia: reorganizing the memory by using alternative intact routes; working with remaining intact memory as the implicit focus, modification of surroundings with 'mnemonics protheses' such as a diary, alarms. The approach must be cognitive for the theoretical support of therapists, but also pragmatic to respect the patient's needs and wishes in the context of family and job. Patient selection must be based not only on rigorous aetiological and neurological grounds but also on an individual and cognitive understanding of each patient.