Clinical features and outcomes of patients with pancreatic cancer requiring unplanned medical ICU admission: A retrospective multicenter study.

BACKGROUND: We sought to describe the reasons for intensive care unit (ICU) admission and outcomes of patients with pancreatic cancer requiring unplanned medical ICU admission. PATIENTS AND METHODS: Retrospective cohort study in five ICUs from 2009 to 2020. All patients with pancreatic cancer admitted to the ICU were included. Patients having undergone recent surgery were excluded (< 4 weeks). RESULTS: 269 patients were included. Tumors were mainly adenocarcinoma (90%). Main reason for admission was sepsis/septic shock (32%) with a biliary tract infection in 44 (51%) patients. Second reason for admission was gastrointestinal bleeding (28%). ICU and 3-month mortality rates were 26% and 59% respectively. Performance status 3-4 (odds ratio OR 3.58), disease status (responsive/stable -ref-, newly diagnosed OR 3.25, progressive OR 5.99), mechanical ventilation (OR 8.03), vasopressors (OR 4.19), SAPS 2 (OR 1.69) and pH (OR 0.02) were independently associated with ICU mortality. Performance status 3-4 (Hazard ratio HR 1.96) and disease status (responsive/stable -ref-, newly diagnosed HR 2.67, progressive HR 4.14) were associated with 3-month mortality. CONCLUSION: Reasons for ICU admissions of pancreatic cancer patients differ from those observed in other solid cancer. Short- and medium-term mortality are strongly influenced by performance status and disease status at ICU admission.

[Metabolic encephalopathies]. / Encéphalopathies métaboliques.

Metabolic encephalopathies (ME) are a common cause of admission to emergency rooms, to hospitalization wards or to intensive care units. They could account for 10 to 20% of causes of comatose states in ICU and could be associated to a poor outcome especially in older patients. Nevertheless, they are often reversible and are associated with a favorable outcome when diagnosed and rapidly treated. They correspond to an altered brain functioning secondary to the deficiency of a substance that is mandatory for the normal brain functioning or to the accumulation of a substance that can be either endogenous or exogenous. It preferably occurs in co-morbid patients, complicating its diagnosis and its management. Altered brain functioning, going from mild neuropsychological impairment to coma, movement disorders especially myoclonus and the absence of any obvious differential diagnosis are highly suggestive of the diagnosis. Whereas some biological samplings and brain MRI are essential to rule out differential diagnosis, some others, such as electroencephalogram, may be able to propose important clues in favor of the diagnosis. Once simple symptomatic measures are introduced, the treatment consists mainly in the correction of the cause. Specific treatment options are only seldom available for ME; this is the case for hepatic encephalopathy and some drug-induced encephalopathies. We will successively describe in this review the main pathophysiological mechanisms, the main causes, favoring circumstances of ME, the differential diagnosis to rule out and the etiological work-up for the diagnosis. Finally, a diagnostic and therapeutic strategy for the care of patients with ME will be proposed.

Early-TIPSS placement prevents rebleeding in high-risk patients with variceal bleeding, without improving survival.

BACKGROUND: Early-TIPSS (transjugular intrahepatic portosystemic shunt) placement may improve rebleeding and reduce 1-year mortality, compared to standard management in high-risk patients with cirrhosis and variceal bleeding. AIM: To obtain external validation of this therapeutic approach. METHODS: We performed a prospective study including all consecutive patients with Child-Pugh C 10-13 cirrhosis or Child-Pugh B with active bleeding at endoscopy admitted to our ICU between March 2011 and February 2013 for variceal bleeding. TIPSS were placed within 72 h after stabilisation. Patients were matched for gender, age, Child-Pugh score, MELD score and to patients from a historical cohort hospitalised before March 2011. RESULTS: 31/128 patients with cirrhosis (77.4% men, mean age 53.2 ± 9.0 years old, MELD score 20.9 ± 6.9, Child-Pugh C: 77.4%) admitted for acute variceal bleeding between March 2011 and February 2013 (TIPSS+ group) were matched to 31 historical patients (TIPSS- group). Uncontrolled bleeding occurred in 1/31 patients in the TIPSS+ group vs. 2/31 patients in TIPSS- group (P = 0.55). The 1-year probability of being free of rebleeding was higher in the TIPSS+ group (97% vs. 51%, P < 0.001). Actuarial 1-year survival was not different between the two groups (66.8 ± 9.4% vs. 74.2 ± 7.8%, P = 0.78). Acute cardiac failure occurred more frequently in the TIPSS+ group (25.8% vs. 6.4%, P = 0.03). CONCLUSIONS: Early-TIPSS placement effectively prevents rebleeding in high-risk patients with variceal bleeding but does not significantly improve survival. This might be due to the high proportion of patients with Child-Pugh C cirrhosis in our series. Cardiac failure may play a role and must be investigated before the procedure, when possible.

Peptic ulcer bleeding in patients with or without cirrhosis: different diseases but the same prognosis?

BACKGROUND: Physiopathology and prognosis of peptic ulcer bleeding (PUB) have never been described in cirrhotic patients. AIM: To assess risk factors and outcome of PUB in two groups of patients with PUB with or without cirrhosis. METHODS: We included prospectively all patients with PUB referred to our ICU of Hepatology and Gastroenterology between January 2008 and March 2011. All patients were treated according to international recommendations. Diagnosis of cirrhosis was based on clinical, biological and morphological exams. Aetiologies, characteristics and outcomes of PUB were compared in cirrhotic vs. noncirrhotic patients. RESULTS: A total of 203 patients with PUB were included prospectively. Twenty-nine patients had cirrhosis (group Cirr+), and 174 patients had no cirrhosis (group Cirr-). Demographic data were similar between the two groups except for age and alcohol consumption. Aetiology of cirrhosis was alcohol in 97% of cirrhotic patients. Characteristics of PUB were not different between the two groups. Ninety-three per cent of patients with cirrhosis had endoscopic portal hypertension. Aetiology of PUB was different between the group Cirr+ and Cirr- (Helicobacter pylori = 10.3% vs. 48.8%, P < 0.0001; NSAID's = 17.2% vs. 54.0%, P < 0.0001; idiopathic PUB = 79.3% vs. 23.8%, P < 0.0001). Outcome was comparable concerning re-bleeding (7.0% vs. 6.9%, P = 0.31), need for arterial embolisation (10.3 vs. 8.6%, P = 0.76), need for salvage surgery (0 vs. 1.7%, P = 0.31) and mortality (3.0% vs. 1.1%, P = 0.87). CONCLUSIONS: Physiopathology of PUB seems to be different in patients with cirrhosis. In cirrhotic patients, PUB occurs almost only in alcoholics. In our series, prognosis was similar to general population. PUB in cirrhosis might be related to portal hypertension and/or alcohol.

Impact of interferon-alpha treatment on liver fibrosis in patients with chronic hepatitis B: an overview of published trials.

BACKGROUND: The impact of interferon treatment in patients with hepatitis B virus (HBV) infection on fibrosis progression in comparison with its natural history has yet to be assessed in any large-scale randomized studies. The present report is a review of the evidence-based data published so far. METHODS: Studies were included if they had at least two repeated estimates of liver fibrosis per patient treated with interferon-alpha (whether pegylated or not). Meta-analysis was performed using a random-effects model. RESULTS: Altogether, 13 studies were included in the review, involving a total of 707 HBV patients treated with interferon-alpha-2a or -2b for 12-83 months. Only one study included pegylated interferon as monotherapy. A total of 787 untreated patients were also followed. Only one study used a non-invasive biomarker. There was a significant reduction in the fibrosis progression rate, with a risk reduction of 0.49 (95% CI: -0.64--0.34; chi(2)=119; degrees of freedom [DF]=6; P<0.0001), and significant heterogeneity (Cochran Q=81; P<0.0001). This significant impact was similar for both randomized (reduction of risk: -0.45; 95% CI: -0.64--0.26; P<0.0001) and not-randomized (controlled) studies (reduction of risk: -0.53; 95% CI: -0.79--0.28; P<0.0001). CONCLUSION: According to these findings, the benefit of interferon treatment on fibrosis progression is clinically significant in patients with advanced fibrosis by the reduction of fibrosis progression to cirrhosis. Pegylated interferon now needs to be compared, in terms of benefit-risk factors, with the new generation of HBV treatments (such as entecavir and tenofovir), using non-invasive biomarkers.

Continuous infusion of high-dose omeprazole is more effective than standard-dose omeprazole in patients with high-risk peptic ulcer bleeding: a retrospective study.

UNLABELLED: High-dose omeprazole reduces the rate of recurrent bleeding after endoscopic treatment of peptic ulcer bleeding. However, the effectiveness of high-dose vs. standard-dose omeprazole in peptic ulcer bleeding has never been shown. AIM: To compare the benefits of high-dose vs. standard-dose omeprazole in peptic ulcer bleeding. METHODS: We reviewed the medical files of patients admitted between 1997 and 2004 for high-risk peptic ulcer bleeding who had undergone successful endoscopic treatment. We distinguished 2 periods: before 2001, standard-dose omeprazole (40 mg/day intravenously until alimentation was possible, then 40 mg/day orally for 1 week); after 2001, high-dose omeprazole (80 mg bolus injection, then 8 mg/h continuous infusion for 72 h, then 40 mg/day orally for 1 week). During both periods, patients subsequently received omeprazole, 20 mg/day, orally for 3 weeks. RESULTS: We enrolled 114 patients (period 1, n = 45, period 2, n = 69). Therapy with high-dose omeprazole significantly decreased the occurrence of poor outcome (27 vs. 12%, P = 0.04), rebleeding (24 vs. 7%, P = 0.01), mortality due to haemorrhagic shock (11 vs. 0%, P < 0.001) and need for surgery (9 vs. 1%, P = 0.05). CONCLUSIONS: In this retrospective study, high-dose omeprazole reduced the occurrence of rebleeding, need for surgery and mortality due to hemorrhagic shock in patients with high-risk peptic ulcer bleeding, as compared with standard-dose omeprazole.

[Medicolegal aspects of acute alcoholic intoxication]. / Aspects médico-légaux de l'alcoolisation aiguë.

The médico-legal aspects of acute alcohol intoxication mainly concern driving while under the effect of alcohol and the regulation thereof. In France, the legal limit is 0.8 mg of alcohol per litre of blood and 0.4 mg per litre of expired air. Examination is made by breathalyser on expired air. In the blood, measurement is performed by oxidation-reduction or gas chromatography, and in the expired air, by alcoholometry. Determination of the level of blood alcohol remains only approximate and a minimal indicator, given the variable number of factors that may intervene.

[Sudden crib death. Experience in a referral center 1986-1991]. / Morts subites au berceau. Expérience d'un centre de référence, 1986-1991.

BACKGROUND: Sudden infant death syndrome (SIDS) may have several etiologies, all of which must be identified in order to recognize those infants believed to be at risk. One of the best ways to do this is by prospective studies on a large population of infants who died of SIDS. METHODS: A total of 171 infants who died from SIDS between January 1, 1986 and June 30, 1991, were studied. 154 infants were completely investigated, including a post mortem examination. They were assigned to one of 4 groups, according to whether death was due to diseases of poor prognosis (group A), diseases that are occasionally fatal but potentially treatable (group B), minor diseases not normally fatal (group C), or was essentially unexplained (group D). RESULTS: The classical risk factors for SIDS were found in this population: incidence peaked in males (sex-ratio 1.5), during the cold seasons (62%), between 1 and 6 months of age (94%), mainly between 1 and 4 months of age (84%). Symptoms were definitely present during the 2 days before death in 50%. 20% of cases had clinical histories of congenital disease, complicated or recurrent postnatal disease, or fulminant recent disease. Group A included 107 infants (69% of the 154 completely investigated patients). Premature birth (17.5%) and low birth weight for gestational age (10.5%) were more frequent in our series than in the normal population. CONCLUSION: The cause of death was identified in about 75% of cases. This possibility improves management of further siblings of SIDS victims even though the variety of risk factors makes prevention of SIDS difficult.

[Pulmonary complications in "sniffers"]. / Complications pulmonaires des "sniffeurs".

When a sudden death occurs, a necropsy is of the upmost value, but sometimes it does not yield the anticipated benefit; in this situation histological study of the specimens may help the diagnosis. We describe two decreased "sniffers" with pulmonary lesions that could have explained their sudden deaths. The histological appearance is often not recognised and considerably worsens the prognosis in subjects inhaling certain drugs.

[Acute ethylene glycol poisoning]. / Intoxication aiguë par l'éthylène glycol

During last 7 years, 13 cases of acute ethylene glycol poisoning have been observed with 4 fatal outbreaks. All cases--except one--were accidental. Six patients had drunk a mixture of antifreeze in water as they were lost in a desert. A patient who had taken 970 ml of ethylene glycol survived. In one case, death was due to irreversible brain damage; two other fatalities occurred from cardiorespiratory distress. CNS involvement was noticed in 8 cases and acute renal failure-constantly controlled-occurred in 9 patients. Post mortem examination has shown bi-refringent calcium oxalate crystals in both kidney and brain. Specific treatment with ethanol has been performed in 3 cases with ingestion of large amounts of toxic who were seen before definitive renal lesions have occurred. Emphasis is placed in symptomatic treatment including gastric lavage, extrarenal epuration and conservative management.