Early life adversity shapes social subordination and cell type-specific transcriptomic patterning in the ventral hippocampus

Adverse events in early life can modulate the response to additional stressors later in life and increase the risk of developing psychiatric disorders. The underlying molecular mechanisms responsible for these effects remain unclear. Here, we uncover that early life adversity (ELA) in mice leads to social subordination. Using single-cell RNA sequencing (scRNA-seq), we identified cell type-specific changes in the transcriptional state of glutamatergic and GABAergic neurons in the ventral hippocampus of ELA mice after exposure to acute social stress in adulthood. These findings were reflected by an alteration in excitatory and inhibitory synaptic transmission induced by ELA in response to acute social stress. Finally, enhancing the inhibitory network function through transient diazepam treatment during an early developmental sensitive period reversed the ELA-induced social subordination. Collectively, this study significantly advances our understanding of the molecular, physiological, and behavioral alterations induced by ELA, uncovering a previously unknown cell type-specific vulnerability to ELA.

Automatically annotated motion tracking identifies a distinct social behavioral profile following chronic social defeat stress

Severe stress exposure increases the risk of stress-related disorders such as major depressive disorder (MDD). An essential characteristic of MDD is the impairment of social functioning and lack of social motivation. Chronic social defeat stress is an established animal model for MDD research, which induces a cascade of physiological and behavioral changes. Current markerless pose estimation tools allow for more complex and naturalistic behavioral tests. Here, we introduce the open-source tool DeepOF to investigate the individual and social behavioral profile in mice by providing supervised and unsupervised pipelines using DeepLabCut-annotated pose estimation data. Applying this tool to chronic social defeat in male mice, the DeepOF supervised and unsupervised pipelines detect a distinct stress-induced social behavioral pattern, which was particularly observed at the beginning of a novel social encounter and fades with time due to habituation. In addition, while the classical social avoidance task does identify the stress-induced social behavioral differences, both DeepOF behavioral pipelines provide a clearer and more detailed profile. Moreover, DeepOF aims to facilitate reproducibility and unification of behavioral classification by providing an open-source tool, which can advance the study of rodent individual and social behavior, thereby enabling biological insights and, for example, subsequent drug development for psychiatric disorders.

Sex-specific and opposed effects of FKBP51 in glutamatergic and GABAergic neurons: Implications for stress susceptibility and resilience

Mental health disorders often arise as a combination of environmental and genetic factors. The FKBP5 gene, encoding the GR co-chaperone FKBP51, has been uncovered as a key genetic risk factor for stress-related illness. However, the exact cell type and region-specific mechanisms by which FKBP51 contributes to stress resilience or susceptibility processes remain to be unravelled. FKBP51 functionality is known to interact with the environmental risk factors age and sex, but so far data on behavioral, structural, and molecular consequences of these interactions are still largely unknown. Here we report the cell type- and sex-specific contribution of FKBP51 to stress susceptibility and resilience mechanisms under the high-risk environmental conditions of an older age, by using two conditional knockout models within glutamatergic (Fkbp5^Nex) and GABAergic (Fkbp5^Dlx) neurons of the forebrain. Specific manipulation of Fkbp51 in these two cell types led to opposing effects on behavior, brain structure and gene expression profiles in a highly sex-dependent fashion. The results emphasize the role of FKBP51 as a key player in stress-related illness and the need for more targeted and sex-specific treatment strategies.

Advancing social behavioral neuroscience by integrating ethology and comparative psychology methods through machine learning

Social behavior is naturally occurring in vertebrate species, which holds a strong evolutionary component and is crucial for the normal development and survival of individuals throughout life. Behavioral neuroscience has seen different influential methods for social behavioral phenotyping. The ethological research approach has extensively investigated social behavior in natural habitats, while the comparative psychology approach was developed utilizing standardized and univariate social behavioral tests. The development of advanced and precise tracking tools, together with post-tracking analysis packages, has recently enabled a novel behavioral phenotyping method, that includes the strengths of both approaches. The implementation of such methods will be beneficial for fundamental social behavioral research but will also enable an increased understanding of the influences of many different factors that can influence social behavior, such as stress exposure. Furthermore, future research will increase the number of data modalities, such as sensory, physiological, and neuronal activity data, and will thereby significantly enhance our understanding of the biological basis of social behavior and guide intervention strategies for behavioral abnormalities in psychiatric disorders.

Metabolic effects of early life stress and pre-pregnancy obesity are long-lasting and sex-specific in mice

Early life stress (ELS) is associated with metabolic-, cognitive-, and psychiatric diseases and has a very high prevalence, highlighting the urgent need for a better understanding of the versatile physiological changes and identification of predictive biomarkers. In addition to programming the hypothalamic-pituitary-axis (HPA), ELS may also affect the gut microbiota and metabolome, opening up a promising research direction for identifying early biomarkers of ELS-induced (mal)adaptation. Other factors affecting these parameters include maternal metabolic status and diet, with maternal obesity shown to predispose offspring to later metabolic disease. The aim of the present study was to investigate the long-term effects of ELS and maternal obesity on the metabolic- and stress phenotype of rodent offspring. To this end, offspring of both sexes were subjected to an adverse early-life experience, and their metabolic and stress phenotypes were examined. In addition, we assessed whether a prenatal maternal and an adult high-fat diet (HFD) stressor further shape observed ELS-induced phenotypes. We show that ELS has long-term effects on male body weight (BW) across the lifespan, whereas females more successfully counteract ELS-induced weight loss, possibly by adapting their microbiota, thereby stabilizing a balanced metabolome. Furthermore, the metabolic effects of a maternal HFD on BW are exclusively triggered by a dietary challenge in adult offspring and are more pronounced in males than in females. Overall, our study suggests that the female microbiota protects against an ELS challenge, rendering them more resilient to additional maternal- and adult nutritional stressors than males.

Introducing a depression-like syndrome for translational neuropsychiatry: a plea for taxonomical validity and improved comparability between humans and mice

Depressive disorders are the most burdensome psychiatric disorders worldwide. Although huge efforts have been made to advance treatment, outcomes remain unsatisfactory. Many factors contribute to this gridlock including suboptimal animal models. Especially limited study comparability and replicability due to imprecise terminology concerning depressive-like states are major problems. To overcome these issues, new approaches are needed. Here, we introduce a taxonomical concept for modelling depression in laboratory mice, which we call depression-like syndrome (DLS). It hinges on growing evidence suggesting that mice possess advanced socioemotional abilities and can display non-random symptom patterns indicative of an evolutionary conserved disorder-like phenotype. The DLS approach uses a combined heuristic method based on clinical depression criteria and the Research Domain Criteria to provide a biobehavioural reference syndrome for preclinical rodent models of depression. The DLS criteria are based on available, species-specific evidence and are as follows: (I) minimum duration of phenotype, (II) significant sociofunctional impairment, (III) core biological features, (IV) necessary depressive-like symptoms. To assess DLS presence and severity, we have designed an algorithm to ensure statistical and biological relevance of findings. The algorithm uses a minimum combined threshold for statistical significance and effect size (p value ≤ 0.05 plus moderate effect size) for each DLS criterion. Taken together, the DLS is a novel, biologically founded, and species-specific minimum threshold approach. Its long-term objective is to gradually develop into an inter-model validation standard and microframework to improve phenotyping methodology in translational research.

Increasing resolution in stress neurobiology: from single cells to complex group behaviors

Stress can have severe psychological and physiological consequences. Thus, inappropriate regulation of the stress response is linked to the etiology of mood and anxiety disorders. The generation and implementation of preclinical animal models represent valuable tools to explore and characterize the mechanisms underlying the pathophysiology of stress-related psychiatric disorders and the development of novel pharmacological strategies. In this commentary, we discuss the strengths and limitations of state-of-the-art molecular and computational advances employed in stress neurobiology research, with a focus on the ever-increasing spatiotemporal resolution in cell biology and behavioral science. Finally, we share our perspective on future directions in the fields of preclinical and human stress research.

Contribution of the co-chaperone FKBP51 in the ventromedial hypothalamus to metabolic homeostasis in male and female mice

Objective

Steroidogenic factor 1 (SF1) expressing neurons in the ventromedial hypothalamus (VMH) have been directly implicated in whole-body metabolism and in the onset of obesity. The co-chaperone FKBP51 is abundantly expressed in the VMH and was recently linked to type 2 diabetes, insulin resistance, adipogenesis, browning of white adipose tissue (WAT) and bodyweight regulation.

Methods

We investigated the role of FKBP51 in the VMH by conditional deletion and virus-mediated overexpression of FKBP51 in SF1-positive neurons. Baseline and high fat diet (HFD)-induced metabolic- and stress-related phenotypes in male and female mice were obtained.

Results

In contrast to previously reported robust phenotypes of FKBP51 manipulation in the entire mediobasal hypothalamus (MBH), selective deletion or overexpression of FKBP51 in the VMH resulted in only a moderate alteration of HFD-induced bodyweight gain and body composition, independent of sex.

Conclusions

Overall, this study shows that animals lacking and overexpressing Fkbp5 in Sf1-expressing cells within the VMH display only a mild metabolic phenotype compared to an MBH-wide manipulation of this gene, suggesting that FKBP51 in SF1 neurons within this hypothalamic nucleus plays a subsidiary role in controlling whole-body metabolism.

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Loss of FKBP51 in SF1 neurons of the VMH induces a mild metabolic phenotype.

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Male and female mice develop similar metabolic responses to the loss of FKBP51.

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VMH-specific overexpression of FKBP51 induces phenotypes comparable to knockout.

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FKBP51 in the VMH mediates whole-body metabolism in a U-shaped manner.

The co-chaperone FKBP51 modulates HPA axis activity and age-related maladaptation of the stress system in pituitary proopiomelanocortin cells

Glucocorticoid (GC)-mediated negative feedback of the hypothalamic-pituitary-adrenal (HPA) axis, the body's physiological stress response system, is tightly regulated and essential for appropriate termination of this hormonal cascade. Disturbed regulation and maladaptive response of this axis are fundamental components of multiple stress-induced psychiatric and metabolic diseases and aging. The co-chaperone FK506 binding protein 51 (FKBP51) is a negative regulator of the GC receptor (GR), is highly stress responsive, and its polymorphisms have been repeatedly associated with stress-related disorders and dysfunctions in humans and rodents. Proopiomelanocortin (Pomc)-expressing corticotropes in the anterior pituitary gland are one of the key cell populations of this closed-loop GC-dependent negative feedback regulation of the HPA axis in the periphery. However, the cell type-specific role of FKBP51 in anterior pituitary corticotrope POMC cells and its impact on age-related HPA axis disturbances are yet to be elucidated. Here, using a combination of endogenous knockout and viral rescue, we show that male mice lacking FKBP51 in Pomc-expressing cells exhibit enhanced GR-mediated negative feedback and are protected from age-related disruption of their diurnal corticosterone (CORT) rhythm. Our study highlights the complexity of tissue- and cell type-specific, but also cross-tissue effects of FKBP51 in the rodent stress response at different ages and extends our understanding of potential targets for pharmacological intervention in stress- and age-related disorders.

Critical COVID-19 patient evacuation on an amphibious assault ship: feasibility and safety. A case series

INTRODUCTION

An amphibious assault ship was deployed on 22 March in Corsica to carry out medical evacuation of 12 critical patients infected with COVID-19. The ship has on-board hospital capacity and is the first time that an amphibious assault ship is engaged in this particular condition. The aim is to evaluate the feasibility and safety of prolonged medical evacuation of critical patients with COVID-19.

METHODS

We included 12 patients with confirmed COVID-19 infection: six ventilated patients with acute respiratory distress syndrome and six non-ventilated patients with hypoxaemia. Transfer on an amphibious assault ship lasted 20 hours. We collected patients' medical records: age, comorbidities, COVID-19 history and diagnosis, ventilation supply and ventilator settings, and blood gas results. We calculated oxygen consumption (OC).

RESULTS

All patients had a medical history. The median delay from onset of symptoms to hospitalisation was 8 (7-10) days. The median Sequential Organ Failure Assessment score on admission was 3 (2-5). There was no significant increase in oxygen during ship transport and no major respiratory complication. There was no significant increase in arterial oxygen pressure to fractional inspired oxygen ratio among ventilated patients during ship transport. Among ventilated patients, the median calculated OC was 255 L (222-281) by hours and 5270 L (4908-5616) during all ship transport. Among non-ventilated patients, the median calculated OC was 120 L (120-480) by hours and 2400 L (2400-9600) during all ship transport.

CONCLUSION

The present work contributes to assessing the feasibility and safety condition of critical COVID-19 evacuation on an amphibious assault ship during an extended transport. The ship needs to prepare a plan and a specialised intensive team and conduct patient screening for prolonged interhospital transfers.

Photon quantum entanglement in the MeV regime and its application in PET imaging

Positron Emission Tomography (PET) is a widely-used imaging modality for medical research and clinical diagnosis. Imaging of the radiotracer is obtained from the detected hit positions of the two positron annihilation photons in a detector array. The image is degraded by backgrounds from random coincidences and in-patient scatter events which require correction. In addition to the geometric information, the two annihilation photons are predicted to be produced in a quantum-entangled state, resulting in enhanced correlations between their subsequent interaction processes. To explore this, the predicted entanglement in linear polarisation for the two photons was incorporated into a simulation and tested by comparison with experimental data from a cadmium zinc telluride (CZT) PET demonstrator apparatus. Adapted apparati also enabled correlation measurements where one of the photons had undergone a prior scatter process. We show that the entangled simulation describes the measured correlations and, through simulation of a larger preclinical PET scanner, illustrate a simple method to quantify and remove the unwanted backgrounds in PET using the quantum entanglement information alone.

Chronic social defeat stress in female mice leads to sex-specific behavioral and neuroendocrine effects

Over the years, it has become increasingly clear that males and females respond differently towards environmental stressors, highlighting the importance of including both sexes when studying the effects of stress. This study aims to provide further insight into the detailed consequences of exposing female mice to 21 days of chronic social defeat stress (CSDS). We used a protocol that relies on the ability of odorants and pheromones in male urine to trigger male mouse aggressive behavior. Collected male C57Bl/6n urine was applied to female C57Bl/6n mice who were then attacked by a novel male CD1 mouse each day according to the CDSD protocol. Control females were pair-housed and handled daily. Physiological, neuroendocrine and behavioral changes were evaluated during the experiment. CSDS exposure resulted in number of physiological changes, such as body weight gain, enlarged adrenals and reduced thymus weight, exaggerated HPA-axis negative feedback and increased anxiety-like behavior. However, no generalized social avoidance behavior was observed. This study provides important insights in the physiological, neuroendocrine and behavioral responses of female mice to CSDS, which are partially dependent on estrous cycle stage. This protocol will allow direct comparison of male and female responses to CSDS and enable sex-specific study of mechanisms underlying individual stress resilience.Lay summaryIn this study we found that there are differences in the way that female and male mice respond towards chronic social stress conditions when it comes to behavior and hormonal changes.

Surgical management of spine injuries in severe polytrauma patients: a retrospective study

Background: Optimal surgical management of spinal injuries as part of life-threatening multiple traumas remains challenging. We provide insights into the surgical management of spinal injuries in polytrauma patients. Methods: All patients from our polytrauma care network who both met at least one positive Vittel criteria and an injury severity score (ISS) >15 at admission and who underwent surgery for a spinal injury were included retrospectively. Demographic data, clinical data demonstrating the severity of the trauma and imaging defining the spinal and extraspinal number and types of injuries were collected.Results: Between January 2012 and December 2016, 302 (22.2%) patients suffered from spinal injury (143 total injuries) and 83 (6.1%) met the inclusion criteria. Mean ISS was 36.2 (16-75). Only 48 (33.6%) injuries led to neurological impairment involving the thoracic (n = 23, 16.1%) and lower cervical (n = 15, 10.5%) spine. The most frequent association of injuries involved the thoracic spine (n = 42). 106 spinal surgeries were performed. The 3-month mortality rate was 2.4%.Conclusions: We present data collected on admission and in the early postoperative period referring to injury severity, the priority of injuries, and development of multi-organ failure. We revealed trends to guide the surgical support of spinal lesions in polytrauma patients.

Vacuum-assisted closure (VAC) for craniocerebral wounds in severely injured patients: technical note of a damage control procedure

The management of a craniocerebral wound (CCW) remains challenging, particularly in a severely injured patient. Considering the complexity of the multilayer insult and damage control care in an unstable patient, every procedure performed should promptly benefit the patient. We report an illustrative case of a patient with a gunshot wound to the head that resulted in a CCW for which we applied vacuum-assisted closure (VAC) therapy according to damage control principles. We describe the technical approach and discuss the indications, results and technique by considering the literature available. VAC can be used for CCWs, particularly for large defects in selected patients according to clinical and CT evaluations following immediate resuscitation. In severely injured and unstable patients, VAC aims to delay definitive reconstructive and time-consuming treatment. Interestingly, it appears to be a safe treatment based on the previously described-but not exclusively trauma-cases with no secondary cerebrospinal fluid leakage encountered.

The 7th French Airborne Forward Surgical Team experience of surgical support to the population of a low-income country: a prospective study on 341 patients with short-term follow-up

BACKGROUND

The 7th Airborne Forward Surgical Team (FST) has deployed to Chad in 2015 and 2016, in support of French military forces. Humanitarian surgical care is known to represent a significant part of the surgical activity in such missions, but to date limited data have been published on the subject.

METHODS

All surgical patients from a civilian host population treated by the FST during these missions have been prospectively included. Indications, operative outcomes and postoperative outcomes were evaluated.

RESULTS

During this period, the FST operated on 358 patients. Humanitarian surgical care represented 95% of the activity. Most patients (92.7%) were operated for elective surgery. Emergencies and infectious diseases represented, respectively, 7.3% and 9.1% of cases. The mean length of stay (LOS) was three days (2-4), and the median follow-up was 30 days (22-34). Mortality rate was 0.6% and morbidity was 5.6%. Parietal surgery had no significant complication and had shorter LOS (p<0.001). Emergent surgeries were more complicated (p<0.01) and required more reoperations (p<0.05). Surgical infectious cases had longer LOS (p<0.01).

CONCLUSIONS

Humanitarian surgical care can be provided without compromising the primary mission of the medical forces. Close surveillance and follow-up allowed favourable outcomes with low morbidity and mortality rates. Humanitarian care is responsible for a considerable portion of the workload in such deployed surgical teams. Accounting for humanitarian care is essential in the planning and training for such future medical operations.

Early transfusion on battlefield before admission to role 2: A preliminary observational study during "Barkhane" operation in Sahel

INTRODUCTION

Haemorrage is the leading cause of death after combat related injuries and bleeding management is the cornerstone of management of these casualties. French armed forces are deployed in Barkhane operation in the Sahel-Saharan Strip who represents an immense area. Since this constraint implies evacuation times beyond doctrinal timelines, an institutional decision has been made to deploy blood products on the battlefield and transfuse casualties before role 2 admission if indicated. The purpose of this study was to evaluate the transfusion practices on battlefield during the first year following the implementation of this policy.

MATERIALS AND METHODS

Prospective collection of data about combat related casualties categorized alpha evacuated to a role 2. Battlefield transfusion was defined as any transfusion of blood product (red blood cells, plasma, whole blood) performed by role 1 or Medevac team before admission at a role 2. Patients' characteristics, battlefield transfusions' characteristics and complications were analysed.

RESULTS

During the one year study, a total of 29 alpha casualties were included during the period study. Twenty-eight could be analysed, 7/28 (25%) being transfused on battlefield, representing a total of 22 transfusion episodes. The most frequently blood product transfused was French lyophilized plasma (FLYP). Most of transfusion episodes occurred during medevac. Compared to non-battlefield transfused casualties, battlefield transfused casualties suffered more wounded anatomical regions (median number of 3 versus 2, p = 0.04), had a higher injury severity score (median ISS of 45 versus 25, p = 0,01) and were more often transfused at role 2, received more plasma units and whole blood units. There was no difference in evacuation time to role 2 between patients transfused on battlefield and non-transfused patients. There was no complication related to battlefield transfusions. Blood products transfusion onset on battlefield ranged from 75 min to 192 min after injury.

CONCLUSION

Battlefield transfusion for combat-related casualties is a logistical challenge. Our study showed that such a program is feasible even in an extended area as Sahel-Saharan Strip operation theatre and reduces time to first blood product transfusion for alpha casualties. FLYP is the first line blood product on the battlefield.

Effectiveness of regional anaesthesia for treatment of facial and hand wounds by emergency physicians: A 9-month prospective study

OBJECTIVE

We compared the effectiveness of nerve blocks (regional anaesthesia, [RA]) versus local anaesthesia (LA) to treat face and hand wounds. Emergency physicians who had not previously used nerve blocks administered the anaesthesia based on anatomic landmarks.

METHODS

This prospective observational open study was conducted at a military teaching hospital emergency department (ED) between May 1, 2013 and January 31, 2014. All patients requiring treatment of facial or hand wounds were included. The primary outcome was anaesthesia effectiveness 15minutes post-administration. We also recorded the number of injections sites, injected volume, pain of administration, operator comfort, and complications. Lidocaine anaesthesia without epinephrine was used.

RESULTS

Of the 1090 treated patients, 617 patients were included in the analysis: 316 with hand wounds and 301 with facial wounds. Overall, 130 wrist blocks and 63 facial blocks were performed. RA effectiveness was comparable to that of LA: for facial wounds, RA=88.9% versus LA=89% (P=0.86); for hand wounds, RA=82.2% versus LA=90.1% (P=0.15). RA groups had significantly fewer injections than the LA groups, and less anesthetic was injected in the facial RA group. The pain of anaesthesia administration and operator comfort was similar. There was no complication during the 9-month data collection period.

CONCLUSION

Facial and wrist nerve blocks are easy to administer and as efficient as local infiltrations, plus they require fewer injection sites, and, for facial RA, less anesthetic. Their teaching and use should be more widespread in EDs.

Damage control: Concept and implementation

The concept of damage control (DC) is based on a sequential therapeutic strategy that favors physiological restoration over anatomical repair in patients presenting acutely with hemorrhagic trauma. Initially described as damage control surgery (DCS) for war-wounded patients with abdominal penetrating hemorrhagic trauma, this concept is articulated in three steps: surgical control of lesions (hemostasis, sealing of intestinal spillage), physiological restoration, then surgery for definitive repair. This concept was quickly adapted for intensive care management under the name damage control resuscitation (DCR), which refers to the modalities of hospital resuscitation carried out in patients suffering from traumatic hemorrhagic shock within the context of DCS. It is based mainly on specific hemodynamic resuscitation targets associated with early and aggressive hemostasis aimed at prevention or correction of the lethal triad of hypothermia, acidosis and coagulation disorders. Concomitant integration of resuscitation and surgery from the moment of admission has led to the concept of an integrated DCR-DCS approach, which enables initiation of hemostatic resuscitation upon arrival of the injured person, improving the patient's physiological status during surgery without delaying surgery. This concept of DC is constantly evolving; it stresses management of the injured person as early as possible, in order to initiate hemorrhage control and hemostatic resuscitation as soon as possible, evolving into a concept of remote DCR (RDCR), and also extended to diagnostic and therapeutic radiological management under the name of radiological DC (DCRad). DCS is applied only to the most seriously traumatized patients, or in situations of massive influx of injured persons, as its universal application could lead to a significant and unnecessary excess-morbidity to injured patients who could and should undergo definitive treatment from the outset. DCS, when correctly applied, significantly improves the survival rate of war-wounded.

Feasibility and limits of inguinal hernia repair under local anaesthesia in a limited resource environment: a prospective controlled study

PURPOSE

Local anaesthesia (LA) has proven effective for inguinal hernia repair in developed countries. Hernias in low to middle income countries represent a different issue. The aim of this study was to analyse the feasibility of LA for African hernia repairs in a limited resource environment.

METHODS

Data from patients who underwent herniorrhaphy under LA or spinal anaesthesia (SA) by the 6th and 7th Forward Surgical Team were prospectively collected. All of the patients benefited from a transversus abdominis plane (TAP) block for postoperative analgesia. Primary endpoints concerned the pain response and conversion to general anaesthesia. Secondary endpoints concerned the complication and recurrence rates. Predictors of LA failure were then identified.

RESULTS

In all, 189 inguinal hernias were operated during the study period, and 119 patients fulfilled the inclusion criteria: 57 LA and 62 SA. Forty-eight percent of patients presented with inguinoscrotal hernias. Local anaesthesia led to more pain during surgery and necessitated more administration of analgesics but resulted in fewer micturition difficulties and better postoperative pain control. Conversion rates were not different. Inguinoscrotal hernia and a time interval <50 min between the TAP block and skin incision were predictors of LA failure. Forty-four patients were followed-up at one month. No recurrence was noted.

CONCLUSIONS

Local anaesthesia is a safe alternative to SA. Small or medium hernias can easily be performed under LA in rural centres, but inguinoscrotal hernias required an ultrasound-guided TAP block performed 50 min before surgery to achieve optimal analgesia, and should be managed only in centres equipped with ultrasonography.

Coagulopathy and transfusion requirements in war related penetrating traumatic brain injury. A single centre study in a French role 3 medical treatment facility in Afghanistan

INTRODUCTION

Traumatic brain injury associated coagulopathy is frequent, either in isolated traumatic brain injury in civilian practice and in combat traumatic brain injury. In war zone, it is a matter of concern because head and neck are the second most frequent site of wartime casualty burden. Data focusing on transfusion requirements in patients with war related TBI coagulopathy are limited.

MATERIALS AND METHODS

A descriptive analysis was conducted of 77 penetrating traumatic brain injuries referred to a French role 3 medical treatment facility in Kabul, Afghanistan, deployed on the Kabul International Airport (KaIA), over a 30 months period.

RESULTS

On 77 patients, 23 died during the prehospital phase and were not included in the study. Severe traumatic brain injury represented 50% of patients. Explosions were the most common injury mechanism. Extracranial injuries were present in 72% of patients. Traumatic brain injury coagulopathy was diagnosed in 67% of patients at role 3 admission. Red blood cell units (RBCu) were transfused in 39 (72%) patients, French lyophilized plasma (FLYP) in 41 (76%), and fresh whole blood (FWB) in 17 (31%).

CONCLUSION

The results of this study support previous observations of coagulopathy as a frequent complication of traumatic brain injury. The majority of patients with war related penetrating traumatic brain injury presented with extracranial lesions. Most of them required a high level of transfusion capacity.

Assessment of cerebral oxygenation in neurocritical care patients: comparison of a new four wavelengths forehead regional saturation in oxygen sensor (EQUANOX®) with brain tissue oxygenation. A prospective observational study

BACKGROUND

Because of restricted information given by monitoring solely intracranial pressure and cerebral perfusion pressure, assessment of the cerebral oxygenation in neurocritical care patients would be of interest. The aim of this study was to determinate the correlation between the non-invasive measure regional saturation in oxygen (rSO2) with a third generation NIRS monitor and an invasive measure of brain tissue oxygenation tension (PbtO2).

METHODS

We conducted a prospective, observational, unblinded study including neurocritical care patients requiring a PbtO2 monitoring. Concomitant measurements of rSO2 were performed with a four wavelengths forehead sensor (EQUANOX Advance®) of the EQUANOX® 7600 System. We determined the correlation between rSO2 and PbtO2 and the ability of the rSO2 to detect ischemic episodes defined by a PbtO2 less than 15 mmHg. The rSO2 ischemic threshold was 60%.

RESULTS

During 2 months, 8 consecutives patients, including 275 measurements, were studied. There was no correlation between rSO2 and PbtO2 (r=0.016 [-0.103-0.134], r2=0.0003, P=0.8). On the 86 ischemic episodes detected by PbtO2, only 13 were also detected by rSO2. ROC curve showed the inability for rSO2 to detect cerebral hypoxia episodes (AUC=0.54).

CONCLUSION

rSO2 cannot be used as a substitute for PbtO2 to monitor cerebral oxygenation in neurocritical care patients.

[Thromboelastometric profile of unwashed shed blood after primary knee arthroplasty]

INTRODUCTION

Knee arthroplasty causes significant blood loss. Different blood-saving measures exist like retransfusion of unwashed salvaged blood. Some studies question the quality of this blood and in particular its ability to clot. These studies use "static" coagulation tests reflecting only partially the reality, unlike viscoelastic methods. The main objective of this study was to evaluate the salvaged blood thromboelastometric profile using ROTEM® system and to compare these results with patient venous blood.

MATERIALS AND METHODS

We performed an observational, prospective, single-center study conducted over 3 months in 2013. Agreement of local ethical committee and patient consent were obtained beforehand. All adult patients who underwent a primary total knee arthroplasty were included. A thromboelastometric profile and standard laboratory tests (hemoglobin, platelets count, PT, aPTT, fibrinogen) were performed in the same time on patient venous blood and on unwashed salvaged blood in the PACU.

RESULTS

Twenty patients were included. The median duration of surgery was 93 minutes. Thirteen patients (65%) received tranexamic acid during procedure. The median volume of shed blood was 225 mL. Two patients (10%) received a reinfusion. Analysis of shed blood showed a major deficiency of clotting factor in standard biology (PT<10%) and an absence of clot formation in thromboelastometric test (In-tem®, Ex-tem®, Fib-tem® or Ap-tem®). Compared to venous blood, shed blood had significantly lower hemoglobin levels: 8.8 vs 13.5 g/dL (P<0.0001). Allogenic transfusion concerned 5% of patients.

DISCUSSION

In this work, we confirmed that shed blood was naturally uncoagulable probably due to a multifactorial mechanism involving a major clot factor deficiency and an activation of fibrinolysis.

Evaluation of surgical treatment for ruptured Achilles tendon in 31 athletes

INTRODUCTION

In the past few decades, the incidence of Achilles tendon rupture has increased in parallel with increased sports participation. Although the optimal treatment remains controversial, there is a trend towards surgical treatment in athletes.

HYPOTHESIS

Surgical repair of ruptured Achilles tendon in athlete results in good functional and objective recovery, irrespective of the type of surgery performed. Subsidiarily, are the results different between percutaneous surgery (PS) and standard open surgery (OS)?

MATERIALS AND METHODS

This was a cross-sectional study of 31 patients who presented with a ruptured Achilles tendon that occurred during sports participation. Percutaneous surgery was performed in 16 patients and open surgery in 15 patients between 2005 and 2009. The objective recovery status was evaluated by open chain goniometry, measurement of leg muscle atrophy and assessment of isokinetic strength. The functional analysis was based on the delay, level of sports upon return, AOFAS and VAS for pain.

RESULTS

Our series of Achilles tendon rupture patients consisted of 88% men and 12% women, with an average age of 38 years. In 71% of cases, the rupture occurred during eccentric loading. After a follow-up of 15 months, the muscle atrophy was 13 mm after PS and 24 mm after OS (P=0.01). A strength deficit of 19% in the plantar flexors was found in the two groups. No patient experienced a rerupture. The return to sports occurred at 130 days after PS and 178 days after OS (P=0.005). The average AOFAS score was 94 and the VAS was 0.5. There were no differences in ankle range of motion between the two groups. The majority (77%) of patients had returned to their preinjury level of sports activity.

DISCUSSION

The return to activities of daily living was slower in our study than in studies based in Anglo-Saxon countries; this can be explained by the different sick leave coverage systems. Percutaneous surgery resulted in a faster return to sports (about 130 days) and less muscle atrophy than open surgery. Our results for return to sports and return to preinjury levels were similar to published results for athletes and were independent of the type of surgery performed. The AOFAS score was comparable to published studies. We found no difference in muscle strength between the two surgery groups 15 months after the procedure. Apart from venous thrombosis typically described after lower-limb immobilization, secondary postoperative complications mostly consisted of sural paresthesia, which had resolved at the 15-month postoperative follow-up evaluation.

CONCLUSION

The results of surgical treatment for ruptured Achilles tendon are good overall. By combining the simplicity of conservative treatment and the reliability of standard surgical treatment, percutaneous surgery is the treatment of choice to achieve excellent results. The return to sports occurred earlier, the muscle atrophy was less and the functional score was better in our patients treated by percutaneous surgery.

LEVEL OF EVIDENCE

Level IV.

[Blood transfusion on battlefield. The Kabul hospital experience]

OBJECTIVES

Blood transfusion is an aspect of medical care on the battlefield. French assets include: red blood cell units (RBCu), lyophilized plasma (PLYO), fresh whole blood (FWB) but neither fresh-frozen plasma (FFP) nor platelets. French transfusion strategy in military operations follows the evolution of knowledge and resources. We describe the characteristics of the transfusion at the military hospital in Kabul.

PATIENTS AND METHODS

Retrospective study of records of patients transfused between October 2010 to December 2011 conducted in Kabul from transfusion register. Variables studied were: patient characteristics, biology at admission, type and amount of transfusion products, evolution.

RESULTS

One hundred and twenty-six patients were transfused: 49 military (39%) which 22 French soldier (17%), most of time afghan (n=97; 77%), mean age at 24 years old (3-66). Two hundred and seventy-three RBCu from France were transfused and 350 unused were destroyed. Conditions leading to a transfusion were: 76 war wounds (60%), 21 trauma (17%) and 29 other (23%). In the first 24 hours, patients received in mean: two RBCu (0-12), one unit of FWB (0-18) and two PLYO (0-14). PLYO/RBCu ratio was 1/1.6. A massive transfusion (more than 10 RBCu) concerned 9% of patients. Twenty-seven percent of patients received FWB. We note 17 dead people (13.5%).

CONCLUSION

The use of the FWB and PLYO in substitution of FFP and platelets can provide cares of high quality in a logistically constrained context while controlling costs.