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1.
J Crit Care ; 82: 154766, 2024 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-38479298

RESUMO

BACKGROUND: Cytomegalovirus (CMV) infection is associated with poor outcome in ICU patients. However, data on immunocompromised patients are scarce. This study aims to describe characteristics and outcomes of critically ill hematological patients and CMV infection. CMV disease characteristics and relationship between CMV viral load, CMV disease, coinfections by other pathogens and outcomes are described. METHODS: Retrospective single center study (Jan 2010-Dec 2017). Adult patients, admitted to the ICU, having underlying hematological malignancy and CMV infection were included. Results are reported as median (interquartile) or n (%). Factors associated with hospital mortality or CMV disease were analysed using logistic regression. RESULTS: 178 patients were included (median age 55y [42-64], 69.1% male). Hospital mortality was 53% (n = 95). Median viral load was 2.7 Log [2.3-3.5]. CMV disease occurred in 44 (24.7%) patients. Coinfections concerned 159 patients (89.3%). After adjustment for confounders, need for vasopressors (OR 2.53; 95%CI 1.11-5.97) and viral load (OR 1.88 per Log; 95%CI 1.29-2.85) were associated with hospital mortality. However, neither CMV disease nor treatment were associated with outcomes. Allogeneic stem cell transplantation (OR 2.55; 95%CI 1.05-6.16), mechanical ventilation (OR 4.11; OR 1.77-10.54) and viral load (OR 1.77 per Log; 95%CI 1.23-2.61) were independently associated with CMV disease. Coinfections were not associated with CMV disease or hospital mortality. CONCLUSION: In critically-ill hematological patients, CMV viral load is independently associated with hospital mortality. Conversely, neither CMV disease nor treatment was associated with outcome suggesting viral load to be a surrogate for immune status rather than a cause of poor outcome.


Assuntos
Infecções por Citomegalovirus , Neoplasias Hematológicas , Mortalidade Hospitalar , Unidades de Terapia Intensiva , Carga Viral , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Infecções por Citomegalovirus/mortalidade , Infecções por Citomegalovirus/epidemiologia , Neoplasias Hematológicas/terapia , Neoplasias Hematológicas/mortalidade , Estudos Retrospectivos , Unidades de Terapia Intensiva/estatística & dados numéricos , Adulto , Estado Terminal , Hospedeiro Imunocomprometido , Coinfecção/epidemiologia , Citomegalovirus/isolamento & purificação
2.
Rev Med Interne ; 41(6): 368-374, 2020 Jun.
Artigo em Francês | MEDLINE | ID: mdl-32008801

RESUMO

INTRODUCTION: Blended-learning methods could be a response to student nonattendance. Non-compulsory teaching combining e-learning/interactive face-to-face sessions has been implemented at Paris-Diderot Medical School for the teaching of intensive care and emergency medicine during the 2018/2019 university period. The aim of the study was to assess this newly-implemented blended teaching. METHODS: Questionnaire submitted to the 388 DFASM3 medical students present at the faculty exam of intensive care/emergency medicine. Attendance at a teaching modality was defined by the follow-up of more than half of this teaching modality. Correlations between attendance at e-learning and/or interactive face-to-face sessions, and grade were performed. RESULTS: A total of 358/388 (92%) students participated in this survey. A quarter of the students (88/321 - 25%) reported they usually attended at traditional lectures. Regarding blended-learning, 210/317 (67%) students reported having attended at e-learning courses and 84/321 (27%) attended at interactive face-to-face sessions. The distribution of students according to their attendance at e-learning and/or interactive face-to-face sessions was significantly different (P<0.01). There was a significant correlation (P<0.001) between attendance at e-learning and grade obtained at the faculty exam. Nevertheless, this correlation was also found for these students in another course taught traditionally. Overall, 309/315 (98%) students were satisfied with the blended teaching, 297/318 (93%) wanted its extent to the whole medical school's curriculum. CONCLUSION: The use of combined learning methods reached more students than traditional teachings and allowed the University to focus on its role of knowledge transfer.


Assuntos
Cuidados Críticos , Educação Médica/métodos , Avaliação Educacional , Medicina de Emergência/educação , Práticas Interdisciplinares/métodos , Absenteísmo , Cuidados Críticos/métodos , Cuidados Críticos/organização & administração , Currículo , Educação a Distância/métodos , Educação a Distância/organização & administração , Educação Médica/organização & administração , Medicina de Emergência/métodos , Medicina de Emergência/organização & administração , Hospitais Universitários/organização & administração , Humanos , Ciência da Implementação , Práticas Interdisciplinares/organização & administração , Paris , Satisfação Pessoal , Faculdades de Medicina/organização & administração , Estudantes de Medicina/psicologia , Inquéritos e Questionários , Visitas de Preceptoria/métodos , Visitas de Preceptoria/organização & administração
3.
Rev Med Interne ; 40(9): 609-612, 2019 Sep.
Artigo em Francês | MEDLINE | ID: mdl-31221453

RESUMO

BACKGROUND: Histological diagnosis of systemic granulomatosis may be difficult. The question of the best histological target remains unanswered. CASE: We report here the observation of a patient admitted in intensive care unit for severe hypercalcemia in the context of polylymphadenopathy and constitutional symptoms. Assessment of this hypercalcemia was suggestive of systemic granulomatosis. The CT (computed tomodensitometry) revealed lymphadenopathies of the mediastinum and the hepatic hilus, hepatomegaly and heterogeneous splenomegaly. At this stage, our main hypotheses were: lymphoid hematopathy, sarcoidosis, tuberculosis. An echo-guided biopsy of the spleen allowed the histological diagnosis of systemic granulomatosis suggestive of sarcoidosis, without significant complication in the course. CONCLUSION: This observation illustrates the efficiency and safety of spleen biopsy for the histological diagnosis of systemic granulomatosis.


Assuntos
Sarcoidose/patologia , Baço/patologia , Feminino , Humanos , Biópsia Guiada por Imagem/métodos , Pessoa de Meia-Idade , Ultrassonografia de Intervenção
4.
Ann Intensive Care ; 8(1): 127, 2018 Dec 17.
Artigo em Inglês | MEDLINE | ID: mdl-30560526

RESUMO

BACKGROUND: Transient and persistent acute kidney injury (AKI) could share similar physiopathological mechanisms. The objective of our study was to assess prognostic impact of AKI duration on ICU mortality. DESIGN: Retrospective analysis of a prospective database via cause-specific model, with 28-day ICU mortality as primary end point, considering discharge alive as a competing event and taking into account time-dependent nature of renal recovery. Renal recovery was defined as a decrease of at least one KDIGO class compared to the previous day. SETTING: 23 French ICUs. PATIENTS: Patients of a French multicentric observational cohort were included if they suffered from AKI at ICU admission between 1996 and 2015. INTERVENTION: None. RESULTS: A total of 5242 patients were included. Initial severity according to KDIGO creatinine definition was AKI stage 1 for 2458 patients (46.89%), AKI stage 2 for 1181 (22.53%) and AKI stage 3 for 1603 (30.58%). Crude 28-day ICU mortality according to AKI severity was 22.74% (n = 559), 27.69% (n = 327) and 26.26% (n = 421), respectively. Renal recovery was experienced by 3085 patients (58.85%), and its rate was significantly different between AKI severity stages (P < 0.01). Twenty-eight-day ICU mortality was independently lower in patients experiencing renal recovery [CSHR 0.54 (95% CI 0.46-0.63), P < 0.01]. Lastly, RRT requirement was strongly associated with persistent AKI whichever threshold was chosen between day 2 and 7 to delineate transient from persistent AKI. CONCLUSIONS: Short-term renal recovery, according to several definitions, was independently associated with higher mortality and RRT requirement. Moreover, distinction between transient and persistent AKI is consequently a clinically relevant surrogate outcome variable for diagnostic testing in critically ill patients.

5.
Resuscitation ; 103: 60-65, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-27068401

RESUMO

AIM: Hypoxic hepatitis (HH) may complicate the course of resuscitated out-of-hospital cardiac arrest (OHCA) patients admitted in intensive care unit (ICU). Aims of this study were to assess the prevalence of HH, and to describe the factors associated with HH occurrence and outcome. METHODS: We conducted an observational study over a 6-year period (2009-2014) in a cardiac arrest center. All non-traumatic OHCA patients admitted in the ICU after return of spontaneous circulation (ROSC) and who survived more than 24h were included. HH was defined as an elevation of alanine aminotransferase over 20 times the upper limit of normal during the first 72h after OHCA. Factors associated with HH and ICU mortality were picked up by multivariate logistic regression. RESULTS: Among the 632 OHCA patients included in the study, HH was observed in 72 patients (11.4% (95% CI: 9.0%, 14.1%)). In multivariate analysis, time from collapse to ROSC [OR 1.02 per additional minute; 95% CI (1.00, 1.04); p=0.01], male gender [OR 0.53; 95% CI (0.29, 0.95); p=0.03] and initial shockable rhythm [OR 0.35; 95% CI (0.19, 0.65); p<0.01] were associated with HH occurrence. After adjustment for confounding factors, HH was associated with ICU mortality [OR 4.39; 95% CI (1.71, 11.26); p<0.01] and this association persisted even if occurrence of a post-CA shock was considered in the statistical model [OR 3.63; 95% CI (1.39, 9.48); p=0.01]. CONCLUSIONS: HH is not a rare complication after OHCA. This complication is mainly triggered by the duration of resuscitation and is associated with increased ICU mortality.


Assuntos
Hepatite/epidemiologia , Parada Cardíaca Extra-Hospitalar/complicações , Idoso , Alanina Transaminase/sangue , Reanimação Cardiopulmonar , Feminino , Hepatite/complicações , Hepatite/enzimologia , Humanos , Hipoglicemia/complicações , Hipóxia/complicações , Incidência , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Parada Cardíaca Extra-Hospitalar/mortalidade , Fatores de Tempo
7.
Rev Med Interne ; 36(9): 588-95, 2015 Sep.
Artigo em Francês | MEDLINE | ID: mdl-25778852

RESUMO

Hyperviscosity syndrome is a life-threatening complication. Clinical manifestations include neurological impairment, visual disturbance and bleeding. Measurement of plasma or serum viscosity by a viscometer assesses the diagnosis. Funduscopic examination is a key exam because abnormalities are well-correlated with abnormal plasma viscosity. Etiologies are various but symptomatic hyperviscosity is more common in Waldenström's macroglobulinemia and multiple myeloma. Prompt treatment is needed: treatment of the underlying disease should be considered, but generally not sufficient. Symptomatic measures aim to not exacerbate blood viscosity while urgent plasmapheresis effectively reduces the paraprotein concentration and relieves symptoms.


Assuntos
Transtornos da Coagulação Sanguínea/terapia , Viscosidade Sanguínea , Hemorragia/terapia , Transtornos da Coagulação Sanguínea/diagnóstico , Transtornos da Coagulação Sanguínea/etiologia , Testes de Coagulação Sanguínea , Angiofluoresceinografia , Hemorragia/diagnóstico , Hemorragia/etiologia , Humanos , Oftalmoscopia , Síndrome , Macroglobulinemia de Waldenstrom/diagnóstico , Macroglobulinemia de Waldenstrom/terapia
8.
J Thromb Haemost ; 13(3): 380-9, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25523333

RESUMO

BACKGROUND: Among patients with thrombotic microangiopathies, acute kidney injury (AKI) is the hallmark of hemolytic uremic syndrome (HUS) and is largely underestimated in patients with thrombotic thrombocytopenic purpura (TTP). OBJECTIVE: We sought to report AKI features and outcomes in patients with TTP. METHODS: We conducted a retrospective study of 92 patients with TTP assessed by low ADAMTS13 activity (< 10%) between 2001 and 2013. A logistic regression identified variables independently associated with AKI. RESULTS: Among the 92 patients, 54 (58.7%) presented with AKI, including 25 (46.3%) with stage 3 AKI. Fourteen (27.4%) patients had a nephrotic-range proteinuria and 21 (45.6%) had hemoglobinuria. Hematuria and leucocyturia were detected in 19 (41.3%) and 16 patients (36.4%), respectively. Renal replacement therapy (RRT) was required in 14 patients (25.9%). Six months after TTP remission, RRT-free patients had median (IQR) MDRD (Modification of Diet in Renal Disease formula estimating the glomerular filtration rate) of 93 mL min(-1) per 1.73 m(2) (68.8-110) and three patients required long-term dialysis. Mild or moderate chronic renal disease occurred in 23/54 (42.6%) AKI patients. By multivariate analysis, serum level of complement component 3 at admission was the only factor independently associated with AKI (OR per 0.25 unit decrease of C3, 0.85; CI, 1.82-8.33; P = 0.001). CONCLUSIONS: In patients with TTP, AKI is present in more than half the patients, and half of those will have lasting renal effects. Further studies to better understand the pathophysiology of renal involvement in patients with TTP and to identify a subset of patients with TTP syndrome overlapping HUS are warranted.


Assuntos
Proteínas ADAM/sangue , Injúria Renal Aguda/epidemiologia , Púrpura Trombocitopênica Trombótica/enzimologia , Proteína ADAMTS13 , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/fisiopatologia , Injúria Renal Aguda/terapia , Adulto , Biomarcadores/sangue , Distribuição de Qui-Quadrado , Complemento C3/análise , Regulação para Baixo , Feminino , Taxa de Filtração Glomerular , Humanos , Incidência , Rim/fisiopatologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Paris/epidemiologia , Prevalência , Púrpura Trombocitopênica Trombótica/sangue , Púrpura Trombocitopênica Trombótica/diagnóstico , Púrpura Trombocitopênica Trombótica/epidemiologia , Recuperação de Função Fisiológica , Terapia de Substituição Renal , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
9.
Transpl Infect Dis ; 16(4): 588-96, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24966154

RESUMO

BACKGROUND: Kidney transplant recipients are at risk for life-threatening infections, which may affect the long-term prognosis. METHODS: We retrospectively included all kidney transplant recipients admitted for sepsis, severe sepsis, or septic shock to the medical intensive care unit (ICU) of the Saint-Louis Hospital, Paris, France, between 2000 and 2010. The main objective was to identify factors associated with survival without graft impairment 90 days after ICU discharge. RESULTS: Data were available for 83 of 100 eligible patients. The main sites of infection were the lungs (54%), urinary tract (24%), and bloodstream (22%). Among documented infections (55/83), 80% were bacterial. Fungal infections were more common among patients transplanted after 2005 (5% vs. 23%, P = 0.02). Mechanical ventilation was used in 46 (56%) patients, vasopressors in 39 (47%), and renal replacement therapy (RRT) in 34 (41%). In-hospital and day-90 mortality rates were 20% and 22%, respectively. On day 90, among the 65 survivors, 39 (47%) had recovered their previous graft function and 26 (31%) had impaired graft function, including 16 (19%) who were dependent on RRT. Factors independently associated with day-90 survival and graft function recovery were baseline serum creatinine (odds ratio [OR] for a 10 µmol/L increase 0.94, 95% confidence interval [CI] 0.88-1.00) and cyclosporine therapy (OR 0.30, 95% CI 0.11-0.79). CONCLUSION: Sepsis was chiefly related to bacterial pneumonia or urinary tract infection. Pneumocystis jirovecii was the leading opportunistic agent, with a trend toward an increase over time. Infections often induced severe graft function impairment. Baseline creatinine and cyclosporine therapy independently predicted the outcome.


Assuntos
Infecções Bacterianas/etiologia , Rejeição de Enxerto , Hospitalização , Unidades de Terapia Intensiva , Transplante de Rim/efeitos adversos , Infecções Oportunistas/microbiologia , Infecções Bacterianas/tratamento farmacológico , Infecções Bacterianas/patologia , Humanos , Imunossupressores/uso terapêutico , Pneumocystis carinii , Pneumonia por Pneumocystis/etiologia , Pneumonia por Pneumocystis/microbiologia , Estudos Retrospectivos , Fatores de Risco
11.
Am J Transplant ; 9(8): 1816-25, 2009 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-19538494

RESUMO

Neutropenic episodes in kidney transplant patients are poorly characterized. In this retrospective study, neutropenia was experienced by 112/395 patients (28%) during the first year posttransplant. The only factor found to be significantly associated with the occurrence of neutropenia was combined tacrolimus-mycophenolate therapy (p < 0.001). Neutropenic patients experienced more bacterial infections (43% vs. 32%, p = 0.04). Grade of neutropenia correlated with the global risk of infection. Discontinuation of mycophenolic acid (MPA) due to neutropenia was associated with an increased incidence of acute rejection (odds ratios per day 1.11, 95% confidence intervals 1.02-1.22) but not with reduced renal function at 1 year. The time from onset of neutropenia to MPA discontinuation correlated with the duration of neutropenia. Granulocyte colony-stimulating factor (G-CSF) administration was safe and effective in severely neutropenic kidney graft recipients, with absolute neutrophil count >1000/microL achieved in a mean of 1.5+/-0.5 days. Neutropenia is an important and frequent laboratory finding that may exert a significant influence on outcomes in kidney transplantation. As well as leading to an increased incidence of infection, it is associated with a higher rate of allograft rejection if MPA is discontinued for >6 days (p = 0.02). G-CSF accelerates recovery of neutropenia and may be a good therapeutic alternative for severely neutropenic patients.


Assuntos
Infecções Bacterianas/etiologia , Transplante de Rim/efeitos adversos , Neutropenia/complicações , Neutropenia/epidemiologia , Adulto , Idoso , Quimioterapia Combinada , Feminino , Rejeição de Enxerto/epidemiologia , Rejeição de Enxerto/prevenção & controle , Fator Estimulador de Colônias de Granulócitos/uso terapêutico , Humanos , Imunossupressores/efeitos adversos , Imunossupressores/uso terapêutico , Incidência , Transplante de Rim/imunologia , Masculino , Pessoa de Meia-Idade , Ácido Micofenólico/efeitos adversos , Ácido Micofenólico/análogos & derivados , Ácido Micofenólico/uso terapêutico , Neutropenia/tratamento farmacológico , Estudos Retrospectivos , Fatores de Risco , Tacrolimo/efeitos adversos , Tacrolimo/uso terapêutico
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