Beneficial of adding Tocilizumab to standard care in critical forms of Covid-19 pneumonia: Study on paired series.

INTRODUCTION: Tocilizumab (TCZ), a humanized monoclonal antibody directed against interleukin-6 (IL-6) receptors, has been tried in various studies as a Covid-19 therapy with controversial results. AIM: To evaluate the effectiveness of adding TCZ to standard care (SC) in critical Covid-19 patients. METHODS: it was designed retrospectively as a comparative study on two paired series of critical patients affected with Covid-19: the 1st group received TCZ plus SC versus a 2nd group which received only SC. The matching criteria were age, sex and severity score and the matching was based on the propensity score matching (PSM) by the nearest neighbor. Outcomes were: survival, mechanical ventilation (MV) and nosocomial infections. RESULTS: Ninety patients were included by pairing estimated successful (PSM > 0.5 in more than 50% in each group for all matching criteria). 55.5% of SC group progressed to stage 3-acute respiratory distress syndrome (ARDS) versus 31% of TCZ+SC patients (p=0.03). No effect of TCZ was found on mortality (49% in each group, p=1) nor on MV use (p=0.67). ICU stay was more prolonged in TCZ+SC group (16 versus 8 days, p<10-3). The administration of TCZ induced a significant decrease in CRP but not changed the IL-6 dosage. Nosocomial infections occurred in 18 (40%) of TCZ+SC group comparatively to 15 (33,5%) of SC group, p=0.66. CONCLUSION: Tocilizumab reduced the risk of progression to severe ARDS probably due to its immune-modulating properties. But no beneficial effect was found on survival or on the use of ventilation.

Toxin-induced cardiac arrest: frequency, causative agents, management and hospital outcome.

BACKGROUND: Cardiac arrest (CA) is a public health problem, with various etiologies and a fatal issue in 90-95% of cases. Toxin-induced cardiac arrests (TICA) are poorly described. Scarcity of national data prompted us to carry-out this study. AIM: To determine TICA frequency in a Tunisian reference center in toxicology and its hospital prognosis, and to describe its clinical and therapeutic aspects Methods : Data were collected retrospectively over an 8-years period. We included patients admitted for post-CA care with highly suspected or confirmed TICA. Clinical and toxicological data were recorded. RESULTS: We recorded 21 cases of TICA, which represented 48.8% of CA. A single toxic agent was incriminated in 90% of cases. Main causative agents identified in our series were pesticides and betablockers: chloralosed (n = 6), carbamate inhibitor of cholinesterase (n = 5), acebutolol (n = 4) and organophosphate (n = 2). One case of opiates and cocaine poisoning was reported. Median duration of "no flow" was 0 minutes. Mean duration of "low flow" was 13.74±9.15 minutes. An initial shockable rhythm was noted only in three patients. Mortality rate was 76% (16/21). Four of the five survivors had a Cerebral Performance Category Scale (CPC) 1, only one patient survived with a CPC 3. Factors associated with mortality were : the duration of "low flow" (p=0.02) and APACHE II score (p=0.014). APACHE II≥29 was the only independent factor (OR=2.0, 95%CI [1.07;3.71]). CONCLUSION: TICA were most frequently provoked by pesticides, mortality was high and was independently predicted by APACHE II score.

Impact of an intensive care unit diary on psychological distress in patients and relatives*.

OBJECTIVE: To assess the impact of an intensive care unit diary on the psychological well-being of patients and relatives 3 and 12 months after intensive care unit discharge. DESIGN: Prospective single-center study with an intervention period between two control periods. SETTING: Medical-surgical intensive care unit in a 460-bed tertiary hospital. PATIENTS: Consecutive patients from May 2008 to November 2009 and their relatives. Study inclusion occurred after the fourth day in the intensive care unit. INTERVENTIONS: A diary written by both the patient's relatives and the intensive care unit staff. MEASUREMENTS AND MAIN RESULTS: Patients and relatives completed the Hospital Anxiety and Depression Scale and Peritraumatic Dissociative Experiences Questionnaire 3 months after intensive care unit discharge, and completed the Impact of Events Scale assessing posttraumatic stress-related symptoms 12 months after intensive care unit discharge. Of the 378 patients admitted during the study period, 143 were included (48 in the prediary period, 49 in the diary period, and 46 in the postdiary period). In relatives, severe posttraumatic stress-related symptoms after 12 months varied significantly across periods (prediary 80%, diary 31.7%, postdiary 67.6%; p<.0001). Similar results were obtained in the posttraumatic stress-related symptom score after 12 months in the surviving patients (prediary 34.6 ± 15.9, diary 21 ± 12.2, and postdiary 29.8 ± 15.9; p = .02). CONCLUSIONS: The intensive care unit diary significantly affected posttraumatic stress-related symptoms in relatives and surviving patients 12 months after intensive care unit discharge.

Compressive pleural effusion after ovarian hyperstimulation syndrome--a case report and review.

OBJECTIVE: To report a case of early onset ovarian hyperstimulation with massive pleural effusion and respiratory failure before IVF. DESIGN: Case report. SETTING: University teaching intensive care unit. PATIENT(S): A 26-year-old healthy woman with an unexplained infertility transferred to the intensive care unit on day 4 after hCG injection for early severe presentation of ovarian hyperstimulation syndrome with massive compressive pleural effusion before she underwent embryo transfer. INTERVENTION(S): Mechanical ventilation, thoracocentesis. MAIN OUTCOME MEASURE(S): Resolution of symptoms/stopping of embryos transfer. RESULT(S): Drainage of 5,300 mL of sterile exudative pleural fluid for a period of 48 hours, which permitted resolution of symptoms and allowed mechanical weaning. The IVF procedure was stopped. CONCLUSION(S): This case described is unusual in that the patient presented with early massive pleural effusion on day 4 after hCG injection and before embryo transfer. This is much earlier than in any case report elsewhere.

Epidemiology and risk factors for colonization and infection by Acinetobacter baumannii in an ICU in Tunisia, where this pathogen is endemic.

Because Acinetobacter baumannii has become an alarming endemic pathogen in our country we decided to conduct this prospective study, from January 2004 to December 2005, in order to determine risk factors and outcomes involved in clinical colonization or infection by A. baumannii in a 16-bed Tunisian intensive care unit (ICU). One hundred and two A. baumannii isolates were obtained from 63 patients, with an infection rate of 45%. The rate of multidrug-resistant (MDR) A. baumannii was 39% during the 2-year study, with an epidemic outbreak in October 2004. This outbreak was followed by closure of all the involved ICU rooms and the selective intestinal decontamination of patients, with polymyxin. During the 12-month post-intervention program (January-December 2005), the infection rate declined. The analysis of risk factors for the spread of A. baumannii showed that only the Simplified Acute Physiological Score (SAPS II) was involved. On the other hand, no risk factor was identified for multidrug resistance in patients either colonized or infected by A. baumannii. There was a statistically significant difference only in crude mortality (67.5% in MDR A. baumannii vs 46.7% in susceptible A. baumannii; P = 0.04).

Methanol poisoning in Tunisia: report of 16 cases.

Methanol poisoning continues to be a public health problem in Tunisia in spite of the different legislative measures. We report a series of 16 cases of methanol poisoning admitted to our Intensive Care Unit between December 2003 and April 2004. The patients' median age was 21.5 years (range 16 to 53 years) with a median SAPS II of 14 (range 12 to 84) and an APACHE II of 8 (range 6 to 36). The median latent period was 9.5 hours (range 4 to 24 hours) with a delay to medical consultation of 36 hours (range 6 to 48 hours), and a median serum methanol concentration of 1.4 g/L (range 0.19 to 3.62 g/L). Clinical signs included central nervous system symptoms (69%), gastrointestinal complaints (87%), visual disturbances (69%) and metabolic acidosis (94%). Three patients (19%) required mechanical ventilation because of deep coma or shock and died within 6 hours. Hemodialysis was performed in eleven patients (69%) because of visual disturbances and/or metabolic acidosis. One patient developed irreversible bilateral blindness and another unilateral blindness secondary to optic neuropathy. Statistical significant risk factors for the developing of visual disturbances were found to be the ingested quantity of methanol, the latent period, acidosis and serum methanol concentration on admission.

Prognostic value of human erythrocyte acetyl cholinesterase in acute organophosphate poisoning.

Acute organophosphate poisoning (OPP) such as dichlorvos may be monitored by the measurement of the erythrocyte acetyl cholinesterase (EAChE) and the serum cholinesterase (SChE) activities. The aim of this study was to look at correlation between the severity of the OPP judged by certain parameters such as coma, hemodynamic disturbances, respiratory failure, and the decrease of cholinesterases enzymes including EAChE and SChE at admission. Cholinesterase activity was determined upon admission and then on days 3 and 15 in the morning. Clinical effects, EAChE, and SChE activities data were investigated in 42 patients with OPP aged of 29.6 +/- 11.8 years with acute cholinergic crisis in all cases. They were comatose in 29% of cases, presenting both hypotension or shock and hypoxemia in 17% of cases. Fifteen of them (36%) required mechanical ventilation. The mean EAChE activity at admission was 24.3 +/- 11.6 micromol/mL per hour at 37 degrees C; it was 1260 +/- 2204 IU/L for SChE. There were no correlations between the EAChE and the SChE activities. The EAChE was decreased only in comatose patients and those presenting hypotension, hypoxemia, and bradycardia with a cutoff of 23.5 micromol/mL per hour at 37 degrees C. Death was observed in 2 patients with a deep decrease of the EAChE at 5 micromol/mL per hour at 37 degrees C in 1 case and 9 micromol/mL per hour at 37 degrees C in another. The kinetics of improvement of the EAChE activity below the cutoff showed the absence of statistical improvement of the EAChE activity on day 3 (16.6 +/- 9 vs 19.5 +/- 5.7 micromol/mL per hour at 37 degrees C); this improvement was remarkable on day 15 (16.6 +/- 9 vs 27.5 +/- 6.5micromol/mL per hour at 37 degrees C, P = .0004). In summary, the marked decrease of EAChE activity appears in this study as prognostic factor in acute OPP, and coma, respiratory failure, hemodynamic disturbances, and death are associated with a decrease of the EAChE of less than 23.5 micromol/mL per hour at 37 degrees C.

Impact of ceftazidime restriction on gram-negative bacterial resistance in an intensive care unit.

The present study included three periods: (1) a 12-month pre-restriction and control period in 2001; (2) a 12-month restriction period with reduced ceftazidime prescribing in favor of piperacillin-tazobactam (2002); (3) and a 24 month post-restriction period (2003-2004). Note that, for results, P represents the difference between 2002 and 2001; P', the difference between 2003 and 2001; and P'', the difference between 2004 and 2001. No changes in hygiene practices were observed during these three periods. The purpose of this study was to assess the effect of reducing ceftazidime use in an intensive care unit (ICU) upon Gram-negative bacterial resistance, particularly as regards Pseudomonas aeruginosa. During the three periods of the study, patients were similar concerning age, Simplified Acute Physiology Score (SAPSII), the site of nosocomial infection, and the requirements for mechanical ventilation (75% in 2001, 76% in 2002, 74% in 2003, and 85% in 2004). The most commonly isolated pathogens were P. aeruginosa, Acinetobacter baumannii, and Enterobacteriaceae. The use of ceftazidime decreased significantly from 12.6% in 2001 to 9% in 2002, to 3% in 2003 (P' = 0.0009), and 2.6% in 2004 (P'' = 0.0001) in favor of piperacillin-tazobactam (0% 2001 to 3.7% in 2003; P' = 0.002; and 5% in 2004; P'' = 0.0001). Simultaneously, we observed a significant decrease in isolates of P. aeruginosa resistant to piperacillin-tazobactam (P = 0.03; P' = 0.004; P'' = 0.009), and those resistant to imipenem in 2003 (P' = 0.008). We also noted a significant decrease in A. baumannii isolates resistant to ceftazidime (P' = 0.01; P'' = 0.0004) and those resistant to imipenem in both 2002 and 2004 (P = 0.03; P'' = 0.04), and a considerable decrease in isolates of Klebsiella pneumoniae producing expanded spectrum betalactamase (ESBL) in 2003 and 2004 (P' = 0.04; P'' = 6.10(-5)). In contrast, we noted an increase in penicillinase-producing isolates of K. pneumoniae, from 6% in 2001 to 16% in 2002 (p = 0.01), 20% in 2003 (P' = 0.001), and 32% in 2004 (P'' = 10(-6)). We concluded that restriction of ceftazidime use was demonstrated to be efficient in reducing antimicrobial resistance, especially to K. pneumoniae ESBL.

Acute myocarditis and myocardial infarction induced by Paraphenylenediamine poisoning. Interest of angiocoronarography.

We present 2 cases of myocardial damage induced by Paraphenylenediamine (PPD) poisoning in young patients without any history of cardiovascular disease. ECG findings revealed the presence of localized ST segment elevation in precordial leads (V1-V4) in the first case and (V3-V6) in the second associated to an increase of the serum troponine T level at 23 ng/ml (case 1) and 29.7 ng/ml (case 2). The transthoracic echocardiography was in favour of diffuse myocarditis in the first case and of localized myocarditis or septo-apical myocardial infarction in the second. The angiocoronarography performed for the first time in the second case conclude on a septo-apical hypokinesia of the left ventricular resulting of a coronary spasm of the anterior interventricular artery.

Acute pancreatitis subsequent to voluntary methomyl and dichlorvos intoxication.

INTRODUCTION: Acute pancreatitis subsequent to methomyl (Lannate) had not been reported until 2005, when Markides published the first case. In our study, we report for the first time 2 cases of acute pancreatitis complicating voluntary methomyl intoxication and compare them with 5 cases of pancreatitis subsequent to dichlorvos poisoning admitted to our toxicological unit during the same period, between July 2001 and June 2003. CASE REPORTS: Patients included in this study were seriously poisoned because all developed muscarinic and nicotinic syndromes. Deep coma and respiratory failure requiring mechanical ventilation were noted in all methomyl-poisoned patients and in only 3 dichlorvos-poisoned patients. Acute pancreatitis occurred 24 to 72 hours after dosing and was characterized by painless abdominal paralytic ileus and vomiting. Clinical features and laboratory examinations were normalized by the fifth day under medical treatment. Complications such as intrapancreatic fluid collection occurred later between days 10 and 20 in 1 methomyl-poisoned patient who required secondary surgical drainage and in 1 dichlorvos-poisoned patient who was treated conservatively. Outcome was favorable in all cases. CONCLUSION: The developing of acute pancreatitis is a serious adverse effect following insecticide intoxication and is better known with dichlorvos than methomyl.