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SUMMARY Accurate motor performance depends on the integration in spinal microcircuits of sensory feedback information. Hand grasp is a skilled motor behavior known to require cutaneous sensory feedback, but spinal microcircuits that process and relay this feedback to the motor system have not been defined. We sought to define classes of spinal interneurons involved in the cutaneous control of hand grasp in mice, and show that dI3 interneurons, a class of dorsal spinal interneurons marked by expression of Isl1, convey input from low threshold cutaneous afferents to motoneurons. Mice in which the output of dI3 interneurons has been inactivated exhibit deficits in motor tasks that rely on cutaneous afferent input. Most strikingly, the ability to maintain grip strength in response to increasing load is lost following genetic silencing of dI3 interneuron output. Thus, spinal microcircuits that integrate cutaneous feedback crucial for paw grip rely on the intermediary role of dI3 interneurons.

for the Prevention of Severe Pneumonia and Endotracheal Colonization Trial (PROSPECT) Investigators and the Canadian Critical Care Trials Group IMPORTANCE Growing interest in microbial dysbiosis during critical illness has raised questions about the therapeutic potential of microbiome modification with probiotics. Prior randomized trials in this population suggest that probiotics reduce infection, particularly ventilator-associated pneumonia (VAP), although probiotic-associated infections have also been reported.OBJECTIVE To evaluate the effect of Lactobacillus rhamnosus GG on preventing VAP, additional infections, and other clinically important outcomes in the intensive care unit (ICU). DESIGN, SETTING, AND PARTICIPANTS Randomized placebo-controlled trial in 44 ICUs in Canada, the United States, and Saudi Arabia enrolling adults predicted to require mechanical ventilation for at least 72 hours. A total of 2653 patients were enrolled from October 2013 to March 2019 (final follow-up, October 2020). INTERVENTIONS Enteral L rhamnosus GG (1 × 10 10 colony-forming units) (n = 1321) or placebo (n = 1332) twice daily in the ICU. MAIN OUTCOMES AND MEASURES The primary outcome was VAP determined by duplicate blinded central adjudication. Secondary outcomes were other ICU-acquired infections including Clostridioides difficile infection, diarrhea, antimicrobial use, ICU and hospital length of stay, and mortality. RESULTS Among 2653 randomized patients (mean age, 59.8 years [SD], 16.5 years), 2650 (99.9%) completed the trial (mean age, 59.8 years [SD], 16.5 years; 1063 women [40.1%.]with a mean Acute Physiology and Chronic Health Evaluation II score of 22.0 (SD, 7.8) and received the study product for a median of 9 days (IQR, 5-15 days). VAP developed among 289 of 1318 patients (21.9%) receiving probiotics vs 284 of 1332 controls (21.3%; hazard ratio [HR], 1.03 (95% CI, 0.87-1.22; P = .73, absolute difference, 0.6%, 95% CI, -2.5% to 3.7%). None of the 20 prespecified secondary outcomes, including other ICU-acquired infections, diarrhea, antimicrobial use, mortality, or length of stay showed a significant difference. Fifteen patients (1.1%) receiving probiotics vs 1 (0.1%) in the control group experienced the adverse event of L rhamnosus in a sterile site or the sole or predominant organism in a nonsterile site (odds ratio, 14.02; 95% CI, 1.79-109.58; P < .001).CONCLUSIONS AND RELEVANCE Among critically ill patients requiring mechanical ventilation, administration of the probiotic L rhamnosus GG compared with placebo, resulted in no significant difference in the development of ventilator-associated pneumonia. These findings do not support the use of L rhamnosus GG in critically ill patients.

To mitigate future risk to limb and skin, we recommend that methylene blue infusions be delivered via central venous catheter. Extra care should be given to patients with risk factors for extravasation, such as sedation, presence of systemic disease, proximal intravenous puncture sites, and improperly placed catheters.

Nos constatations suggèrent que l'OA par lunettes nasales est associée à un moindre risque de désaturation en oxygène au cours des intubations en urgence. Cependant, compte de tenu de l'hétérogénéité des études, d'autres essais de grande qualité sont nécessaires pour déterminer quels patients pourraient bénéficier de l'OA au cours des intubations d'urgence.

BackgroundUltrasound is being used increasingly to diagnose pathological free fluid accumulation at the bedside. In addition to the detection of peritoneal and pericardial fluid, point-of-care ultrasound allows rapid bedside diagnosis of pleural fluid.FindingsIn this short report, we describe the sonographic observation of the vertebral or ‘V-line’ to help confirm the presence of pleural fluid in the supine patient. The V-line sign is a result of the fluid acting as an acoustic window to enable visualization of vertebral bodies and posterior thoracic wall, thus confirming the presence of pleural fluid.ConclusionsThe V-line is a useful sonographic sign to aid the diagnosis of pleural free fluid.

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Patients may present to Emergency Departments (ED) in shock for various reasons. Emergency medicine physicians may require the use of vasopressors or inotropes to manage these patients. The Critical Care Practice Committee of the Canadian Association of Emergency Physicians (C4) conducted an intensive literature search and guideline development process to help create an evidence based approach for use of these agents in the stabilization of shock. Strong Recommendations:Cardiogenic shock patients in the ED should receive norepinephrine as the first-line vasopressor. Norepinephrine is the first line vasopressor for use in septic shock. Dobutamine should be used for septic shock with low cardiac output despite adequate volume resuscitation. Epinephrine infusion is the preferred agent for anaphylactic shock that does not respond to intramuscular or intravenous bolus epinephrine. In undifferentiated shock not responding to fluid resuscitation, norepinephrine should be the first line vasopressor. Conditional Recommendations:Cardiogenic shock patients in the ED should receive dobutamine if an inotrope is deemed necessary. Routine vasopressor use in hypovolemic shock is not recommended. Vasopressin may be indicated in hemorrhagic or hypovolemic shock if a vasopressor is deemed necessary. In obstructive shock not responding to indicated treatment, a systemically active vasopressor should be instituted. For patients with known or suspected hypertrophic obstructive cardiomyopathy (HOCM) or dynamic outflow obstruction, inotropic agents should be avoided. Judicious use of vasoconstrictive agents can be considered. Vasopressin should be considered in cathecholamine refractory septic shock. Vasopressor choice in neurogenic shock is not clear. The agent should be determined by patient characteristics and response to treatment. Norepinephrine is the first line agent for the management of distributive shock due to hepatic failure. Vasopressor choice in distributive shock secondary to adrenal insufficiency not responding to steroid replacement is not clear. Patient response to chosen agents should guide therapy.