Purpose To compare bacteria recovered by standard cultures and metataxonomics, particularly with regard to ventilator-associated pneumonia (VAP) pathogens, and to determine if the presence of particular bacteria or microbiota in tracheal and oropharyngeal secretions during the course of intubation was associated with the development of VAP. Methods In this case–control study, oropharyngeal secretions and endotracheal aspirate were collected daily in mechanically ventilated patients. Culture and metataxonomics (16S rRNA gene-based taxonomic profiling of bacterial communities) were performed on serial upper respiratory samples from patients with late-onset definite VAP and their respective controls. Results Metataxonomic analyses showed that a low relative abundance of Bacilli at the time of intubation in the oropharyngeal secretions was strongly associated with the subsequent development of VAP. On the day of VAP, the quantity of human and bacterial DNA in both tracheal and oropharyngeal secretions was significantly higher in patients with VAP than in matched controls with similar ventilation times. Molecular techniques identified the pathogen(s) of VAP found by culture, but also many more bacteria, classically difficult to culture, such as Mycoplasma spp. and anaerobes. Conclusions Molecular analyses of respiratory specimens identified markers associated with the development of VAP, as well as important differences in the taxa abundance between VAP and controls. Further prospective trials are needed to test the predictive value of these markers, as well as the relevance of uncultured bacteria in the pathogenesis of VAP. Electronic supplementary material The online version of this article (10.1007/s00134-019-05660-8) contains supplementary material, which is available to authorized users.

BackgroundIn the ICU, out-of-bed rehabilitation is often delayed and in-bed exercises are generally low-intensity. Since the majority of rehabilitation is carried out in bed, it is essential to carry out the exercises that have the highest intensity. The aim of this study was to compare the physiological effects of four common types of bed exercise in intubated, sedated patients confined to bed in the ICU, in order to determine which was the most intensive.MethodsA randomised, single-blind, placebo-controlled crossover trial was carried out to evaluate the effects of four bed exercises (passive range of movements (PROM), passive cycle-ergometry, quadriceps electrical stimulation and functional electrical stimulation (FES) cycling) on cardiac output. Each exercise was carried out for ten minutes in ventilated, sedated patients. Cardiac output was recorded using cardiac Doppler ultrasound. The secondary aims were to evaluate right heart function and pulmonary and systemic artery pressures during the exercises, and the microcirculation of the vastus lateralis muscle.ResultsThe results were analysed in 19 patients. FES cycling was the only exercise that increased cardiac output, with a mean increase of 1 L/min (15%). There was a concomitant increase in muscle oxygen uptake, suggesting that muscle work occurred. FES cycling thus constitutes an effective early rehabilitation intervention. No muscle or systemic effects were induced by the passive techniques.ConclusionMost bed exercises were low-intensity and induced low levels of muscle work. FES cycling was the only exercise that increased cardiac output and produced sufficient intensity of muscle work. Longer-term studies of the effect of FES cycling on functional outcomes should be carried out.Trial registrationClinicalTrials.gov, NCT02920684. Registered on 30 September 2016.Prospectively registered.

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Due to its low prevalence, epidemiologic data on afibrinogenemia are limited and none are available on health-related quality of life (HRQoL). We conducted a cross-sectional international study to characterize the clinical features, the fibrinogen supplementation modalities and their impact on HRQoL in patients with afibrinogenemia. A total of 204 patients (119 adults and 85 children) from 25 countries were included. The bleeding phenotype was severe: 68 (33.3%) patients having at least one bleed per month and 48 (23%) a history of cerebral bleeding. About 35% (n=72) of patients were treated with fibrinogen concentrates or cryoprecipitates as prophylaxis, 18.1% (n=37) received more than one injection per week and 16.6% (n=34) were on home treatment. A thrombotic event was reported in venous and/or arterial territories by 37 (18.1%) patients. Thrombosis occurred even in young patients and recurrence was frequent (7.4%). The total HRQoL was lower in children than in adults. Discomfort linked to treatment and limitations to sports and leisure were the main concerns. Women and children were particularly affected in family relationships. In multivariate analyses, younger age, residence in Asia or Africa and a previous thrombotic event were statistically correlated with a worse HRQoL. In conclusion, our study underlines the severe bleeding and thrombotic phenotype and their impact on HRQoL in afibrinogenemia. The optimal strategy for fibrinogen supplementation needs to be determined.

Background Identifying patients at high risk of hospital preventable readmission is an essential step towards selecting those who might benefit from specific transitional interventions. Objective Derive and validate a predictive risk score for potentially avoidable readmission (PAR) based on analysis of readmissions, with a focus on medication. Design/Setting/Participants Retrospective analysis of all hospital admissions to internal medicine wards between 2011 and 2014. Comparison between patients readmitted within 30 days and non-readmitted patients, as identified using a specially designed algorithm. Univariate and multivariate regression analyses of demographic data, clinical diagnoses, laboratory results, and the medication data of patients admitted during the first period (2011–2013), to identify factors associated with PAR. Using these, derive a predictive score with a regression coefficient-based scoring method. Subsequently, validate this score with a second cohort of patients admitted in 2013–2014. Variables were identified at hospital discharge. Results The derivation cohort included 7,317 hospital stays. Multivariate logistic regressions found significant associations with PAR for: [adjusted OR (95% CI)] hospital length of stay > 4 days [1.3 (1.1–1.7)], admission in previous 6 months [2.3 (1.9–2.8)], heart failure [1.3 (1.0–1.7)], chronic ischemic heart disease [1.7 (1.2–2.3)], diabetes with organ damage [2.2 (1.3–3.8)], cancer [1.4 (1.0–1.9)], metastatic carcinoma [1.9 (1.3–3.0)], anemia [1.2 (1.0–1.5)], hypertension [1.3 (1.1–1.7)], arrhythmia [1.3 (1.0–1.6)], hyperkalemia [1.4 (1.0–1.7)], opioid drug prescription [1.3 (1.1–1.6)], and acute myocardial infarction [0.6 (0.4–0.9)]. The PAR-Risk Score, derived from these results, demonstrated fair discriminatory and calibration power (C-statistic = 0.699; Brier Score = 0.069). The results for the validation cohort’s operating characteristics were similar (C-statistic = 0.687; Brier Score = 0.064). Conclusion This study identified routinely-available factors that were significantly associated with PAR. A predictive score was derived and internally validated.