Clinical Practice: Should we Radically Alter our Sedation of Critical Care Patients, Especially Given the COVID-19 Pandemics?

The high number of patients infected with the SARS-CoV-2 virus requiring care for ARDS puts sedation in the critical care unit (CCU) to the edge. Depth of sedation has evolved over the last 40 years (no-sedation, deep sedation, daily emergence, minimal sedation, etc.). Most guidelines now recommend determining the depth of sedation and minimizing the use of benzodiazepines and opioids. The broader use of alpha-2 adrenergic agonists ('alpha-2 agonists') led to sedation regimens beginning at admission to the CCU that contrast with hypnotics+opioids ("conventional" sedation), with major consequences for cognition, ventilation and circulatory performance. The same doses of alpha-2 agonists used for 'cooperative' sedation (ataraxia, analgognosia) elicit no respiratory depression but modify the autonomic nervous system (cardiac parasympathetic activation, attenuation of excessive cardiac and vasomotor sympathetic activity). Alpha-2 agonists should be selected only in patients who benefit from their effects ('personalized' indications, as opposed to a 'one size fits all' approach). Then, titration to effect is required, especially in the setting of systemic hypotension and/or hypovolemia. Since no general guidelines exist for the use of alpha-2 agonists for CCU sedation, our clinical experience is summarized for the benefit of physicians in clinical situations in which a recommendation might never exist (refractory delirium tremens; unstable, hypovolemic, hypotensive patients, etc.). Because the physiology of alpha-2 receptors and the pharmacology of alpha-2 agonists lead to personalized indications, some details are offered. Since interactions between conventional sedatives and alpha-2 agonists have received little attention, these interactions are addressed. Within the existing guidelines for CCU sedation, this article could facilitate the use of alpha-2 agonists as effective and safe sedation while awaiting large, multicentre trials and more evidence-based medicine.

Observational Study Investigating the Prescription of Lipid-Lowering Drugs for Primary and/or Secondary Prevention in Residents Aged 80 Years and Over Institutionalized in Nursing Homes in Brest.

OBJECTIVES: To evaluate the prescription of lipid-lowering therapy in nursing home residents aged 80 and older. DESIGN: Observational descriptive study, led in Brest, France, between February and May 2017. SETTING: 15 nursing homes in Brest, France. PARTICIPANTS: Nursing home residents, aged 80 and older, treated with a lipid-lowering therapy for primary and / or secondary prevention. MEASUREMENTS: The primary endpoint was to observe the frequency of prescription of lipid-lowering therapy at the time of the study. The secondary endpoints were to analyse the relevance of these prescriptions regarding the latest French recommendations and current literature data and to evaluate the monitoring of treatment. RESULTS: 213 of the 1121 included residents (19%) were treated with a lipid-lowering drugs. A total of 141 prescriptions (66.2%) were considered irrelevant. In the past 12 months, monitoring of lipids, liver and muscle enzymes was observed respectively in 41.3%, 60.1% and 9.4% of residents. CONCLUSION: lipid-lowering prescription was not optimal in nursing homes. The results highlighted inadequate treatment monitoring and a gap between the French National Authority for Health (HAS) recommendations and actual practice.

Hypothesis: Fever control, a niche for alpha-2 agonists in the setting of septic shock and severe acute respiratory distress syndrome?

During severe septic shock and/or severe acute respiratory distress syndrome (ARDS) patients present with a limited cardio-ventilatory reserve (low cardiac output and blood pressure, low mixed venous saturation, increased lactate, low PaO2/FiO2 ratio, etc.), especially when elderly patients or co-morbidities are considered. Rescue therapies (low dose steroids, adding vasopressin to noradrenaline, proning, almitrine, NO, extracorporeal membrane oxygenation, etc.) are complex. Fever, above 38.5-39.5°C, increases both the ventilatory (high respiratory drive: large tidal volume, high respiratory rate) and the metabolic (increased O2 consumption) demands, further limiting the cardio-ventilatory reserve. Some data (case reports, uncontrolled trial, small randomized prospective trials) suggest that control of elevated body temperature ("fever control") leading to normothermia (35.5-37°C) will lower both the ventilatory and metabolic demands: fever control should simplify critical care management when limited cardio-ventilatory reserve is at stake. Usually fever control is generated by a combination of general anesthesia ("analgo-sedation", light total intravenous anesthesia), antipyretics and cooling. However general anesthesia suppresses spontaneous ventilation, making the management more complex. At variance, alpha-2 agonists (clonidine, dexmedetomidine) administered immediately following tracheal intubation and controlled mandatory ventilation, with prior optimization of volemia and atrio-ventricular conduction, will reduce metabolic demand and facilitate normothermia. Furthermore, after a rigorous control of systemic acidosis, alpha-2 agonists will allow for accelerated emergence without delirium, early spontaneous ventilation, improved cardiac output and micro-circulation, lowered vasopressor requirements and inflammation. Rigorous prospective randomized trials are needed in subsets of patients with a high fever and spiraling toward refractory septic shock and/or presenting with severe ARDS.

Static and elevated pollen traps do not provide an accurate assessment of personal pollen exposure.

SUMMARY: Background. Volumetric pollen traps are commonly used to assess pollen exposure. These traps are well suited for estimating the regional mean airborne pollen concentration but are likely not to provide an accurate index of personal exposure. In this study, we tested the hypothesis that hair sampling may provide different pollen counts from those from pollen traps, especially when the pollen exposure is diverse. Methods. We compared pollen counts in hair washes to counts provided by stationary volumetric and gravimetric pollen traps in 2 different settings: urban with volunteers living in short distance from one another and from the static trap and suburban in which volunteers live in a scattered environment, quite far from the static trap. Results. Pollen counts in hair washes are in full agreement with trap counts for uniform pollen exposure. In contrast, for diverse pollen exposure, .individual pollen counts in hair washes vary strongly in quantity and taxa composition between individuals and dates. These results demonstrate that the pollen counts method (hair washes vs. stationary pollen traps) may lead to different absolute and relative contributions of taxa to the total pollen count. Conclusions. In a geographic area with a high diversity of environmental exposure to pollen, static pollen traps, in contrast to hair washes, do not provide a reliable estimate of this higher diversity.

Acute iterative bronchospasm and "do not re-intubate" orders: sedation by an alpha-2 agonist combined with noninvasive ventilation.

A male patient presented with bronchospasm and acute respiratory distress. The patient had presented 2 previous episodes of severe bronchospasm following abdominal surgery, leading twice to intubation, mechanical ventilation, and conventional sedation. As the patient positively rejected a third episode of intubation + mechanical ventilation, noninvasive ventilation (pressure support = 8 cm H2O, positive end-expiratory pressure = 10 cm H2O), inhaled therapy, and clonidine orally (≈ 4 µg/kg) were combined. Over 1 to 2 hours, the acute respiratory distress disappeared. Noninvasive ventilation was discontinued on the next morning (day 2). The patient was discharged from the critical care unit on day 3 on good condition but died at a later interval from iterative bronchospasm. Evidence-based documentation of the effects of alpha-2 agonists in the setting of acute bronchospasm in the emergency department or status asthmaticus in the critical care unit is awaited.

Pressor Response to Noradrenaline in the Setting of Septic Shock: Anything New under the Sun-Dexmedetomidine, Clonidine? A Minireview.

Progress over the last 50 years has led to a decline in mortality from ≈70% to ≈20% in the best series of patients with septic shock. Nevertheless, refractory septic shock still carries a mortality close to 100%. In the best series, the mortality appears related to multiple organ failure linked to comorbidities and/or an intense inflammatory response: shortening the period that the subject is exposed to circulatory instability may further lower mortality. Treatment aims at reestablishing circulation within a "central" compartment (i.e., brain, heart, and lung) but fails to reestablish a disorganized microcirculation or an adequate response to noradrenaline, the most widely used vasopressor. Indeed, steroids, nitric oxide synthase inhibitors, or donors have not achieved overwhelming acceptance in the setting of septic shock. Counterintuitively, α 2-adrenoceptor agonists were shown to reduce noradrenaline requirements in two cases of human septic shock. This has been replicated in rat and sheep models of sepsis. In addition, some data show that α 2-adrenoceptor agonists lead to an improvement in the microcirculation. Evidence-based documentation of the effects of alpha-2 agonists is needed in the setting of human septic shock.

Swift recovery of severe hypoxemic pneumonia upon morbid obesity.

A morbidly obese (body mass index = 55.5) female patient presented with severe hypoxemic community acquired pneumonia [PaO2/FiO2 (P/F) = 57] with primarily right basal atelectasis, but without bilateral opacities in the upper lobes on the chest X-ray. Major O2 desaturations led the nurses to object to moving the patient to the prone position: muscle relaxation combined to prone position was impossible. Therefore, stringent 60 degrees reverse Trendelenburg legs down position was constantly maintained during mechanical ventilation through the endotracheal tube, using low pressure support (pressure support = 5-10 cmH2O) and high positive end-expiratory pressure (PEEP). PEEP was progressively increased to 20 cmH2O, and little or no sedation was used. A P/F improvement from 57 to 200 over three days allowed removing the tracheal tube. The patient was discharged 13 days after admission. In this paper, the use of high PEEP in the context of morbid obesity, and low pressure support are discussed.

[Cypress pollen allergy]. / Allergie au pollen de cyprès.

Cypress belongs to the Cupressaceae family, which includes 140 species with non-deciduous foliage. The most important genera in allergic diseases are Cupressus sempervirens or Green cypress, Cupressus arizonica or Blue cypress, Juniperus oxycedrus, Juniperus communis and Thuya. Because J. oxycedrus pollinates in October, C. sempervirens in January and February, C. arizonica in February and March, J. communis in April, the symptomatic period is long-lasting. Because of global warming, the pollination period is tending to last longer and Cupressaceae species are becoming established further the north. In Mediterranean countries, cypress is by far the most important pollinating species, accounting for half of the total pollination. The major allergens belong to group 1. The other allergens from cypress and Juniper share 75 to 97 % structural homology with group 1 major allergens. The prevalence of cypress allergy in the general population ranges from 5 % to 13 %, according to exposure to the pollen. Among outpatients consulting an allergist, between 9 and 35 %, according to different studies, are sensitized to cypress pollen. Repeated cross-sectional studies performed at different time intervals have demonstrated a threefold increase in the percentage of cypress allergy. Risk factors include a genetic predisposition and/or a strong exposure to pollen, but air pollutants could play a synergistic role. The study of the natural history of cypress allergy allows the identification of a subgroup of patients who have no personal or family history of atopy, whose disease began later in life, with low total IgE and often monosensitization to cypress pollen. In these patients, the disease is allergic than rather atopic. In the clinical picture, rhinitis is the most prevalent symptom but conjunctivitis the most disabling. A cross-reactivity between cypress and peach allergy has been demonstrated. The pharmacological treatment of cypress allergy is not different from that for other allergies. Hyposensitization has been used, at first by injection, but nowadays mostly through the sublingual route, but clinical trials have included few patients. Avoidance can be implemented at the individual level but also at the community levels using alternative plants, low-pollinating cypresses or by trimming hedges prior to pollination.

Is there a place for pressure-support ventilation and high positive end-expiratory pressure combined to alpha-2 agonists early in severe diffuse acute respiratory distress syndrome?

Acute respiratory distress syndrome (ARDS) is associated with a high mortality linked primarily to co-morbidities (sepsis, cardiac failure, multiple organ failure, etc.). When the lung is the single failing organ, quick resolution of ARDS should skip some complications arising from a prolonged stay in the critical care unit. In severe ARDS (PaO2/FIO2=P/F<100 with positive end-expiratory pressure (PEEP) ≥ 5 cm H2O), current recommendations are to intubate the trachea of the patient and use mechanical ventilation, low tidal volume, high PEEP, prone positioning and possibly neuromuscular blockade in association with intravenous sedation. Another strategy is possible. Firstly, spontaneous ventilation (SV) coupled with pressure support (PS) ventilation and high PEEP is possible from tracheal intubation onwards, with the possible exception of the short period following immediately tracheal intubation. Secondly, using alpha-2 adrenergic agonists (e.g. clonidine, dexmedetomidine) can provide first-line sedation from the beginning of mechanical ventilation, as they preserve respiratory drive, lower oxygen consumption and pulmonary hypertension and increase diuresis. Alpha-2 agonists are to be supplemented, if appropriate, by drugs devoid of effect on respiratory drive (neuroleptics, etc.). The expected benefits would be to prevent acquired diaphragmatic weakness, accumulation of sedation, cognitive dysfunction, and presumably improved outcome. This hypothesis should be tested in a double blind randomized controlled trial.

[Dexmedetomidine and clonidine: a review of their pharmacodynamy to define their role for sedation in intensive care patients]. / Dexmédétomidine et clonidine : revue de leurs propriétés pharmacodynamiques en vue de définir la place des agonistes alpha-2 adrénergiques dans la sédation en réanimation.

Alpha-2 adrenergic agonists ("alpha-2 agonists") present multiple pharmacodynamic effects: rousable sedation, decreased incidence of delirium in the setting of critical care, preservation of respiratory drive, decreased whole body oxygen consumption, decreased systemic and pulmonary arterial impedance, improved left ventricular systolic and diastolic function, preserved vascular reactivity to exogenous catecholamines, preserved vasomotor baroreflex with lowered set point, preserved kidney function, decreased protein catabolism. These pharmacodynamic effects explain the interest for these drugs in the critical care setting. However, their exact role for sedation in critically ill-patients remains open for further studies. Given the few double-blind randomized multicentric trials available, the present non exhaustive analysis of the literature aims at presenting the utilization of alpha-2 agonists as potential first-line sedative agents, in the critical care setting. Suggestions regarding the use of alpha-2 agonists as sedatives are detailed.

Dexmedetomidine and clonidine: from second- to first-line sedative agents in the critical care setting?

In the critical care setting, α-2 agonists present a multifaceted profile: sedation combined with arousability, suppression of delirium, preservation of respiratory drive, reduced O(2) consumption, preserved renal function, and reduced protein metabolism. In addition, this review details the reduced arterial impedance, improved left ventricular performance, preserved vascular reactivity to exogenous amines, preserved cardiac baroreflex reactivity, preserved vasomotor baroreflex activity combined with a lowered pressure set point: these features may explain the good tolerance observed when α-2 agonists are used as continuous infusion without any loading dose. Reviewing the literature allows one to suggest that a new management appears possible with arousable sedation. However, it remains to be demonstrated whether this arousable sedation can be combined with the preservation of spontaneous ventilation, in the setting of severe respiratory distress, as opposed to conventional controlled mechanical ventilation combined with conventional sedation. Should such a speculative view be confirmed, then α-2 agonists will move from second-line sedative agents to first-line sedative agents. However, key studies are lacking to demonstrate the effect of α-2 agonists on physiological endpoints and outcome. Presently, the existing body of data suggests a niche for the use of α-2 agonists in the critical care setting.

Combination of clonidine sedation and spontaneous breathing-pressure support upon acute respiratory distress syndrome: a feasibility study in four patients.

INTRODUCTION: As alpha-2 agonists preserve ventilator drive, patients presenting with acute respiratory distress syndrome (ARDS, Pa02/FiO2 < 200) were managed using sedation with an alpha-2 agonist, clonidine, combined to spontaneous ventilation (SV) + pressure support ventilation (PS). METHODS: Sedation was provided by an alpha-2 agonist, clonidine 1-2 microg x kg(-1( x h(-1), without bolus administration, and supplemented with a neuroleptic, loxapine, if needed. Four patients presenting with ARDS were managed with pressure support ventilation (PS = 8 cm H20,rarely 10-12 cm H20) and high PEEP (10-20 cm H20). Energy requirements were minimized, if appropriate, with hypothermia caused by extra-renal replacement therapy or intentional hypothermia (35-36 degrees C). Repeated echocardiographic examinations revealed no right ventricular failure. RESULTS: Recovery of ARDS, i.e. sustained increase of P/F > 200 for > 24 h, was observed, over 2-5 days. CONCLUSION: Use of an alpha-2 agonist as first-line sedative agent led to absence of respiratory depression and spontaneous ventilation. Upon ARDS, the lowered intrathoracic pressure observed with SV+PSV allowed one to recruit alveoli with high levels of PEEP, without impairing right ventricle function.

Variation of selfing rate and inbreeding depression among individuals and across generations within an admixed Cedrus population.

We investigated the variation and short-term evolution of the selfing rate and inbreeding depression (ID) across three generations within a cedar forest that was established from admixture ca 1860. The mean selfing rate was 9.5%, ranging from 0 to 48% among 20 seed trees (estimated from paternally inherited chloroplast DNA). We computed the probability of selfing for each seed and we investigated ID by comparing selfed and outcrossed seeds within progenies, thus avoiding maternal effects. In all progenies, the germination rate was high (88-100%) and seedling mortality was low (0-12%). The germination dynamics differed significantly between selfed and outcrossed seeds within progenies in the founder gene pool but not in the following generations. This transient effect of selfing could be attributed to epistatic interactions in the original admixture. Regarding the seedling growth traits, the ID was low but significant: 8 and 6% for height and diameter growth, respectively. These rates did not vary among generations, suggesting minor gene effects. At this early stage, outcrossed seedlings outcompeted their selfed relatives, but not necessarily other selfed seedlings from other progenies. Thus, purging these slightly deleterious genes may only occur through within-family selection. Processes that maintain a high level of genetic diversity for fitness-related traits among progenies also reduce the efficiency of purging this part of the genetic load.

Alpha-2 agonists to reduce vasopressor requirements in septic shock?

One of the unsolved problems of septic shock is the poor responsiveness, or reduced vascular reactivity, to vasopressors used to increase blood pressure (BP). Attempts to restore vascular reactivity with NO inhibitors or low dose steroids have met with little success. Low vascular reactivity, which may lead to refractory shock and death, is linked to desensitization or down-regulation of alpha-1 adrenergic receptors. Our working hypothesis is that the use of alpha-2 agonists (e.g. clonidine or dexmedetomidine) in septic shock, in addition to the state-of-the-art treatment (including volume load and vasopressors), will reduce the vasopressor requirements needed to restore adequate BP. This counter-intuitive proposal is based on the fact that alpha-2 agonists will reduce the massive release of endogenous catecholamines. A decrease in plasma endogenous catecholamine concentrations will be followed by reduced down-regulation of alpha-1 receptors and/or a gradual re-sensitization of alpha-1 adrenergic receptors. In turn, this will lead to lowered vasopressor requirement, with respect to dose and duration. Our hypothesis, based on a reverse "denervation hypersensitivity", is at variance with accepted treatments, which rest only on volume load and vasopressors and emphasizes restoration of blood pressure per se. Several observations in the cardiology and anesthesia setting have shown increased vascular reactivity following alpha-2 agonist administration. Our preliminary observations in the setting of septic shock again suggest such increased vascular reactivity. Improved outcome was also observed. Rigorous work is warranted to verify reduced vasopressor requirement and improved outcome, when an alpha-2 agonist is combined with state-of -the-art treatment of septic shock.

Molecular evidence for the natural production of homozygous Cupressus sempervirens L. lines by Cupressus dupreziana seed trees.

Paternal apomixis was recently reported in the endangered Mediterranean cypress, Cupressus dupreziana. This species acts as a surrogate mother for the development of all-paternal embryos from pollen grains. C. dupreziana production of Cupressus sempervirens haploid or diploid seedlings from C. sempervirens pollen was also demonstrated. The haploid progeny was derived from the embryogenic development of haploid gametes, but the origin of the diploid progeny remained unknown. To determine the ontogenic origin of the diploid C. sempervirens progeny, we analyzed the heterozygozity of 63 diploid all-paternal C. sempervirens seedlings using highly variable co-dominant nuclear microsatellite markers. The bi-parental inheritance of the markers was checked in C. sempervirens controlled crosses. A high level of polymorphism was observed among the diploid all-paternal trees. All but three individuals exhibited single-band profiles as expected for homozygotes, which may originate from natural diploidization of a C. sempervirens haploid embryo or from the fusion of two male gametes produced by the same C. sempervirens microgametophyte. The three heterozygous seedlings must be derived from the fusion of male gametes produced by two different C. sempervirens microgametophytes. These findings offer a unique opportunity in conifers to produce homozygous lines, highly valuable for genetic analyses or breeding.

Dasatinib synergizes with doxorubicin to block growth, migration, and invasion of breast cancer cells.

BACKGROUND: Src family kinases control multiple cancer cell properties including cell cycle progression, survival, and metastasis. Recent studies suggest that the Src inhibitor dasatinib blocks these critical cancer cell functions. METHODS: Because the molecular mechanism of action of dasatinib in breast cancers has not been investigated, we evaluated the effects of dasatinib as a single agent and in combination with the commonly used chemotherapeutic doxorubicin, on the proliferation, viability, and invasive capacity of breast cancer cells lines earlier categorised as dasatinib-sensitive (MDA-MB-231) and moderately resistant (MCF7 and T47D). We also tested the effects of these drugs on the actin cytoskeleton and associated signalling pathways. RESULTS: The cell lines tested varied widely in sensitivity to growth inhibition (IC(50)=0.16-12.3 microM), despite comparable Src kinase inhibition by dasatinib (IC(50)=17-37 nM). In the most sensitive cell line, MDA-MB-231, dasatinib treatment induced significant G(1) accumulation with little apoptosis, disrupted cellular morphology, blocked migration, inhibited invasion through Matrigel (P<0.01), and blocked the formation of invadopodia (P<0.001). Importantly, combination treatment with doxorubicin resulted in synergistic growth inhibition in all cell lines and blocked the migration and invasion of the highly metastatic, triple-negative MDA-MB-231 cell line. CONCLUSION: The observed synergy between dasatinib and doxorubicin warrants the re-evaluation of dasatinib as an effective agent in multi-drug regimens for the treatment of invasive breast cancers.

Force measurements between emulsion droplets-ssDNA conjugates: a new tool for medical diagnostics.

We describe here a new system involving direct force measurements between biomolecules that could be used in biomedical diagnostics. The method consists in the use of magnetic emulsion droplets bearing immobilized single stranded DNA fragments (ssDNA, Deoxyribo Nucleic Acid). The immobilized ssDNA fragments are able to recognize complementary DNA molecules via specific hydrogen binding (hybridization process). The ssDNA used in this study are 32 bases oligonucleotides functionalized at their 5' extremity with biotin and then immobilized onto the magnetic nanodroplets via interactions with streptavidin previously chemically grafted onto the nanomagnetic support. The aim of this work is to evaluate the possible detection of captured nucleic acid targets via single force measurements as an alternative to classical ELOSA (Enzyme Linked Oligo Sorbent Assay). The obtained results are discussed mainly in terms of electrostatic interactions.

Allergy to cypress pollen.

Although Cupressus sempervirens has been spread over southern Europe since antiquity, cypress pollen allergy has not been reported until 1945. In France, the very first case reports were published in 1962. Since then, the prevalence of cypress pollinosis seems to demonstrate an upward trend, concomitantly with the increased use of cypress trees as ornamental plants, as wind breaks and as hedges. Hyposensitization, using improved pollen extracts, is increasingly prescribed. Besides, prevention measures begin to be implemented. Such measures include avoidance of planting new cypress trees, especially near human populations' centres, trimming of cypress hedges before the pollination season and agronomical research for hypoallergenic trees. Altogether, such new developments in cypress allergy deserve an update review.