ABSTRACT
The objective of this study was to determine how clinicians make use of the modern multiplex PCR assays (MPAs) to manage patients hospitalized for community-acquired pneumonia (CAP). We studied the use of MPAs in 1648 patients hospitalized for CAP over a 3-year period at the moment of the setup of the new PCR assay. We observed that the use of MPAs for the identification of multiple respiratory pathogens marks a radical change in the investigation of CAP etiology. Surprisingly, the contribution of MPAs to the medical decision-making process varies drastically according to the units of care.
Subject(s)
Clinical Decision-Making/methods , Multiplex Polymerase Chain Reaction , Pneumonia/therapy , Adolescent , Adult , Aged , Aged, 80 and over , Community-Acquired Infections/diagnosis , Community-Acquired Infections/etiology , Community-Acquired Infections/therapy , Cross-Sectional Studies , Female , France , Humans , Male , Middle Aged , Pneumonia/diagnosis , Pneumonia/etiology , Retrospective Studies , Young AdultABSTRACT
BACKGROUND: The estimation of arterial blood gas and lactate from central venous blood analysis and pulse oximetry [Formula: see text] readings has not yet been extensively validated. METHODS: In this multicentre, prospective study performed in 590 patients with acute circulatory failure, we measured blood gases and lactate in simultaneous central venous and arterial blood samples at 6 h intervals during the first 24 h after insertion of central venous and arterial catheters. The study population was randomly divided in a 2:1 ratio into model derivation and validation sets. We derived predictive models of arterial pH, carbon dioxide partial pressure, oxygen saturation, and lactate, using clinical characteristics, [Formula: see text], and central venous blood gas values as predictors, and then tested their performance in the validation set. RESULTS: In the validation set, the agreement intervals between predicted and actual values were -0.078/+0.084 units for arterial pH, -1.32/+1.36 kPa for arterial carbon dioxide partial pressure, -5.15/+4.47% for arterial oxygen saturation, and -1.07/+1.05 mmol litre(-1) for arterial lactate (i.e. around two times our predefined clinically tolerable intervals for all variables). This led to â¼5% (or less) of extreme-to-extreme misclassifications, thus giving our predictive models only marginal agreement. Thresholds of predicted variables (as determined from the derivation set) showed high predictive values (consistently >94%), to exclude abnormal arterial values in the validation set. CONCLUSIONS: Using clinical characteristics, [Formula: see text], and central venous blood analysis, we predicted arterial blood gas and lactate values with marginal accuracy in patients with circulatory failure. Further studies are required to establish whether the developed models can be used with acceptable safety.
Subject(s)
Carbon Dioxide/blood , Critical Illness , Lactic Acid/blood , Oxygen/blood , Humans , Hydrogen-Ion Concentration , Prospective StudiesABSTRACT
BACKGROUND: Antibiotic nebulization theoretically allows the delivery of high doses to the lungs together with limited systemic exposure and toxicity. This study aimed to describe amikacin pharmacokinetics, and especially its absorption, in patients treated with high-dose nebulized amikacin. PATIENTS AND METHODS: Twenty critically ill patients experiencing ventilator-associated pneumonia received a 20 mg/kg infusion of amikacin, followed by either three other infusions or three nebulizations of 60 mg/kg amikacin. An extensive sampling regimen allowed measurement of amikacin serum concentrations at 0.5, 1, 1.5, 2, 3, 4, 6, 10 and 24 h after each administration. Amikacin pharmacokinetics was studied by population compartmental modelling. RESULTS: Amikacin pharmacokinetics was best described using a two-compartment structural model with first-order distribution and elimination, in which lung absorption was described using a transit model. Estimated means (interindividual variability) of the main parameters were: bioavailability Fâ=â2.65% (22.1%); transit compartments nâ=â1.58 (fixed); transit constant ktrâ=â1.38 h-1 (33.4%); central volume Vcâ=â10.2 L (10.5%); and elimination constant k10â=â0.488 h-1 (35.8%). The addition of interoccasion variability on F (44.0%) and k10 (41.7%) allowed the description of intraindividual variability of bioavailability and elimination. Amikacin clearance was positively correlated with baseline creatinine clearance. CONCLUSIONS: Our pharmacokinetic model provided an accurate description of amikacin concentrations following nebulization. There was wide interindividual and interoccasion variability in the absorption and elimination of amikacin. Nevertheless, systemic exposure after nebulization was always much lower than after infusion, an observation suggesting that nebulized high doses are safe in this regard and may be used to treat ventilator-associated pneumonia.
Subject(s)
Aerosols/administration & dosage , Amikacin/administration & dosage , Amikacin/pharmacokinetics , Anti-Bacterial Agents/administration & dosage , Anti-Bacterial Agents/pharmacokinetics , Pneumonia, Ventilator-Associated/drug therapy , Respiration, Artificial , Adult , Aged , Aged, 80 and over , Critical Illness , Female , Humans , Male , Middle Aged , Serum/chemistry , Young AdultABSTRACT
Investigations of the etiologic agents of community-acquired acute respiratory illness may lead to better treatment decisions and patient outcomes. In a routine care setting, we assessed the diagnostic performance of a multiplex PCR assay with respect to conventional microbiological methods, in a continuous series of adult cases of community-acquired acute respiratory illness. We enrolled 279 adult patients hospitalised for community-acquired acute respiratory illness at Tours University Hospital during the winter of 2011-2012. Respiratory samples (mostly nasopharyngeal aspirates) were studied prospectively by indirect immunofluorescence assay and multiplex PCR, that enable detection of 8 viruses and 21 respiratory pathogens respectively. In total, 255 of the 279 (91.4%) samples had interpretable results by both methods. At least one respiratory pathogen was detected by multiplex PCR in 171 specimens (65%). Overall, 130 (76%) of the 171 positive samples were positive for only one respiratory pathogen, 37 (22%) samples were positive for two pathogens and four (2%) were positive for three pathogens. With indirect immunofluorescence assay, a respiratory virus was detected in 27 of the 255 (11%) specimens. Indirect immunofluorescence assay detected some of the influenza virus A (15/51, 29%) infections identified by multiplex PCR and some (7/15, 47%) human metapneumovirus and (5/12, 42%) respiratory syncytial virus infections, but it did not detect all the adenovirus infections. Thus, access to multiplex molecular assays improves the diagnostic spectrum and accuracy over conventional methods, increasing the frequency of identification of the respiratory pathogens involved in community-acquired acute respiratory illness.
Subject(s)
Community-Acquired Infections/diagnosis , Microbiological Techniques/methods , Molecular Diagnostic Techniques/methods , Multiplex Polymerase Chain Reaction/methods , Respiratory Tract Infections/diagnosis , Adolescent , Adult , Aged , Aged, 80 and over , Community-Acquired Infections/epidemiology , Community-Acquired Infections/genetics , Community-Acquired Infections/microbiology , Female , Humans , Male , Middle Aged , Predictive Value of Tests , Respiratory Tract Infections/epidemiology , Respiratory Tract Infections/genetics , Respiratory Tract Infections/microbiology , Young AdultABSTRACT
BACKGROUND: Since the first description of Hashimoto's Encephalitis (HE) in 1966 by Lord Brain, the number of reported cases has continued to increase. In addition, cases of status epilepticus have been reported, suggesting a role for intensive care unit (ICU) practitioners in taking care of patients with HE. METHODS: A retrospective cohort study in ICU patients with HE was performed at the University Hospital of Tours, France. RESULTS: Eight HE cases were admitted to the ICU between 1/1/2000 and 1/1/2012. Herein, we describe the characteristics of the patients, with an emphasis on ICU disease management and its outcome. CONCLUSION: ICU practitioners should be aware of this disease, since it can include life-threatening presentations.
Subject(s)
Brain Diseases/diagnosis , Critical Care/methods , Hashimoto Disease/diagnosis , Status Epilepticus/therapy , Adult , Aged , Aged, 80 and over , Brain Diseases/complications , Brain Diseases/therapy , Cohort Studies , Encephalitis , Female , Hashimoto Disease/complications , Hashimoto Disease/therapy , Humans , Male , Middle Aged , Retrospective Studies , Status Epilepticus/etiologySubject(s)
Extracorporeal Membrane Oxygenation/methods , Respiratory Distress Syndrome/therapy , Ventilator Weaning/methods , Humans , Male , Middle Aged , Parainfluenza Virus 3, Human , Respiration, Artificial , Respiratory Distress Syndrome/etiology , Respirovirus Infections/complications , Respirovirus Infections/therapyABSTRACT
Aortic false aneurysms are rare complications of aortic valve replacement and cardiac surgical procedures in general. Aortic false aneurysms can also presents as a mediastinal mass. A false aneurysm etiology should always be considered in mediastinal mass exploration of patients with a cardiac surgery history. Although, a computed tomography (CT) scan can detect a mediastinal mass, it can equally misdiagnose an aneurysm in the absence of tumour contrast enhancement. We present the case of a 60-year-old woman who was hospitalized for a laryngeal dyspnea. She had undergone aortic valve replacement 3 years earlier and had no other relevant medical history. In the last 3 months, she presented a progressively worsening dyspnea and cough. A chest radiograph showed a large mass in the superior mediastinum. A contrast-enhanced CT-scan showed an anterior mediastinal mass (9 cm × 8 cm × 9 cm) not enhanced by contrast product, suggestive of a tissue density tumour. The mass was in fact an aortic false aneurysm where the communication with the aorta was too narrow to be filled by the contrast product in arterial phase imaging. The aneurysm was excised and successfully replaced with a prosthetic graft during deep hypothermic and circulatory arrest. In this case report, we discuss the unusual clinical presentation of this pseudoaneurysm and the absence of contrast enhancement during CT-scan, which could have lead to a catastrophic error.
Subject(s)
Airway Obstruction/etiology , Aneurysm, False/complications , Aortic Aneurysm, Thoracic/complications , Aneurysm, False/diagnostic imaging , Aortic Aneurysm, Thoracic/diagnostic imaging , Female , Humans , Middle Aged , RadiographySubject(s)
Disease Outbreaks , Encephalitis/epidemiology , Listeria monocytogenes/isolation & purification , Listeriosis/epidemiology , Meningitis, Listeria/epidemiology , Aged , Aged, 80 and over , Anti-Bacterial Agents/therapeutic use , Bacteremia/drug therapy , Bacteremia/microbiology , Brain Damage, Chronic/etiology , Cerebrospinal Fluid Proteins/analysis , Comorbidity , Confusion/etiology , Cranial Nerve Diseases/etiology , Disease Progression , Encephalitis/cerebrospinal fluid , Encephalitis/complications , Encephalitis/drug therapy , Encephalitis/microbiology , Female , France/epidemiology , Humans , Immunocompromised Host , Listeriosis/cerebrospinal fluid , Listeriosis/complications , Listeriosis/drug therapy , Listeriosis/microbiology , Meningitis, Listeria/cerebrospinal fluid , Meningitis, Listeria/complications , Meningitis, Listeria/drug therapy , Meningitis, Listeria/microbiology , Middle AgedSubject(s)
Solitary Fibrous Tumor, Pleural/pathology , Watchful Waiting , Aged, 80 and over , Follow-Up Studies , Humans , Male , Neoplasm Invasiveness , Pneumonectomy , Solitary Fibrous Tumor, Pleural/diagnostic imaging , Solitary Fibrous Tumor, Pleural/surgery , Thoracotomy , Tomography, X-Ray Computed , Treatment OutcomeSubject(s)
Indinavir/blood , Sulfonamides/pharmacology , Adult , Antihypertensive Agents/pharmacology , Antihypertensive Agents/therapeutic use , Area Under Curve , Bosentan , Drug Interactions , HIV Infections/complications , HIV Infections/drug therapy , HIV Protease Inhibitors/pharmacokinetics , HIV Protease Inhibitors/therapeutic use , Humans , Hypertension, Pulmonary/complications , Hypertension, Pulmonary/drug therapy , Indinavir/pharmacokinetics , Indinavir/therapeutic use , Male , Metabolic Clearance Rate , Sulfonamides/therapeutic useSubject(s)
Alcoholism/complications , Bronchoalveolar Lavage , Lung Abscess/diagnosis , Pasteurella Infections/diagnosis , Pasteurella multocida/isolation & purification , Animals , Cats , Fatal Outcome , Humans , Lung Abscess/drug therapy , Lung Abscess/microbiology , Male , Middle Aged , Pasteurella Infections/drug therapy , Tomography, X-Ray Computed , Zoonoses/microbiologyABSTRACT
Diagnosis of exercise-induced anaphylaxis is based on conjunction between a specific factor: a specific or nonspecific food allergy and exercise. The authors report observation of a patient who presented with exercise-induced anaphylaxis associated with food allergy to spinach, but also with a cross reaction with latex.
Subject(s)
Anaphylaxis/etiology , Food Hypersensitivity/diagnosis , Latex Hypersensitivity/diagnosis , Physical Exertion , Spinacia oleracea/adverse effects , Adult , Anaphylaxis/immunology , Cross Reactions , Food Hypersensitivity/complications , Food Hypersensitivity/immunology , Humans , Latex Hypersensitivity/complications , Latex Hypersensitivity/immunology , Male , Skin Tests , Urticaria/etiologyABSTRACT
BACKGROUND: Cutaneous periarteritis nodosa (PAN) is distinguished from systemic PAN by the lack of visceral involvement. The aim of this study was to describe the clinical presentation, laboratory findings, clinical course, and treatment in cutaneous PAN. PATIENTS AND METHODS: We retrospectively reviewed the files of patients hospitalized for vasculitis in our Dermatology unit where approximately 20 cases of vasculitis are seen each year. Inclusion criteria were skin signs suggestive of PAN and a histological image of leukocytoclastic vasculitis of an arteriole. RESULTS: Nine cases of cutaneous PAN were treated in our unit between 1976 and 1997. Follow-up ranged from 32 months to 22 years. No cases of systemic PAN had been diagnosed during this period. These 9 cases of cutaneous PAN all had the same clinical presentation: nodules on the lower limbs in all cases associated with nodules on the upper limbs in half of the cases. Neuropathy was found in 3 of the 9 cases. No systemic involvement was observed. The most frequently used treatment protocol was general corticosteroid therapy (0.5 mg/kg/d prednisone or prednisolone). Immunosuppressive drugs, colchicine, dapsone, non-steroidal anti-inflammatory drugs and intravenous immunoglobulins were also used with efficacy. DISCUSSION: Cutaneous PAN is a particular form of vasculitis associating skin signs with locoregional neuromuscular involvement. The differential diagnosis with other types of vasculitis is sometimes a difficult task. The clinical course is the fundamental diagnostic clue in cutaneous PAN. A benign course and the absence of visceral involvement allow initiating a symptomatic treatment such as colchicine. The development of neuromuscular signs may warrant the use of general corticosteroid therapy.