Christine Zandotti

A contributive result of open-lung biopsy improves survival in acute respiratory distress syndrome patients.

Objective:The impact of a contributive result of open-lung biopsy on the outcome of patients with acute respiratory distress syndrome (ARDS) has not been extensively investigated. The aim of this study was therefore to determine the rate of contributive open-lung biopsy and whether it improved the prognosis of ARDS patients. Design:Prospective study conducted during an 8-yr period. Setting:A 14-bed medico-surgical intensive care unit and a 12-bed medical intensive care unit from the same hospital. Patients:One hundred open-lung biopsies were performed in 100 patients presenting ARDS. Interventions:Open-lung biopsy was performed after ≥5 days of evolution of ARDS when there was no improvement in the respiratory status despite negative microbiological samples cultures and potential indication for corticosteroid treatment. Measurements and Main Results:Ten patients presented a mechanical complication following open-lung biopsy (two pneumothoraces and eight moderate air leaks). The unique independent factor associated with this complication was the minute ventilation when open-lung biopsy was performed (odds ratio, 1.20; 95% confidence interval, 1.03–1.41; p = .02). Fibrosis was noted in 53 patients but was associated with an infection in 29 of these 53 patients (55%). A contributive result of open-lung biopsy (defined as the addition of a new drug) was noted in 78 patients. Simplified Acute Physiology Score II was the only independent predictive factor of a contributive open-lung biopsy (odds ratio, 0.96; 95% confidence interval, 0.92–0.99; p = .04). Survival was higher in patients with a contributive open-lung biopsy (67%) than in patients in whom open-lung biopsy results did not modify the treatment (14%) (p < .001). The factors predicting survival were a contributive result of open-lung biopsy, female gender, and the Organ System Failures score the day of open-lung biopsy. Conclusions:The present study shows that open-lung biopsy provided a contributive result in 78% of ARDS patients with a negative bronchoalveolar lavage. Survival of ARDS patients improved when open-lung biopsy was contributive.

Use of a mobile cart influenza program for vaccination of hospital employees.

OBJECTIVE Rates of annual influenza vaccination of healthcare workers (HCWs) remained low in our university hospital. This study was conducted to evaluate the impact of a mobile cart influenza vaccination program on HCW vaccination. METHODS From 2000 to 2002, the employee health service continued its annual influenza vaccination program and the mobile cart program was implemented throughout the institution. This program offered influenza vaccination to all employees directly on the units. Each employee completed a questionnaire. Vaccination rates were analyzed using the Mantel-Haenszel test. RESULTS The program proposed vaccination to 50% to 56% of the employees. Among the nonvaccinated employees, 52% to 53% agreed to be vaccinated. The compliance with vaccination varied from 61% to 77% among physicians and medical students and from 38% to 55% among nurses and other employees. Vaccination of the chief or associate professor of the unit was associated with a higher vaccination rate of the medical staff (P < .01). Altogether, the vaccination program led to an increase in influenza vaccination among employees from 6% in 1998 and 7% in 1999 before the mobile cart program to 32% in 2000, 35% in 2001, and 32% in 2002 (P < .001). CONCLUSIONS The mobile cart program was associated with a significantly increased vaccination acceptance. Our study was able to identify HCW groups for which the mobile cart was effective and highlight the role of the unit head in its success.

Cytomegalovirus. An unexpected cause of ventilator-associated pneumonia.

Background Cytomegalovirus (CMV) frequently is observed in immunocompromised hosts. The aim of this study was to report cases of ventilator-associated CMV pneumonia diagnosed by pathologic examination in intensive care patients without acquired immunodeficiency syndrome or hematologic malignancy or who were not receiving immunosuppressive agents. Methods From June 1, 1989, to May 31, 1994, 2,785 patients were hospitalized. During the study period, 60 autopsies and 26 open-lung biopsies were performed in nonimmunocompromised patients who were seen with acute respiratory failure and/or symptoms suggestive of ventilator-associated pneumonia. Cytomegalovirus pneumonia was diagnosed using pulmonary samples by the identification of large cells with large nuclei containing a basophilic or eosinophilic inclusion surrounded by a light halo. These typical findings always were associated with a diffuse interstitial pneumonitis. Results Cytomegalovirus pneumonia was diagnosed after histologic examination in 25 patients. The reason for admission to the intensive care unit was major surgery in 13 patients and medical problems in 12 patients. Ventilator-associated CMV pneumonia was diagnosed by histologic examination 22.4+/-8.8 days after admission to the intensive care unit (median 18 days; range 10-40 days). The clinical description was similar with the 25 patients who were seen with ventilator-associated CMV pneumonia and the 61 patients without ventilator-associated CMV pneumonia. However, there was a more severe hypoxemia (72+/-16 vs. 95 +/-41 mmHg, P < 0.05) and a higher Weinbergs radiologic score (9.2+/-1.9 vs. 7.4+/-2.7, P < 0.05) in the ventilator-associated CMV pneumonia group. Diagnosis of ventilator-associated CMV pneumonia was made for 9 of 17 patients when shell-vial culture technique using fluorescein-labeled antibody E 13 was performed on bronchoalveolar lavage products. Four of the eight patients treated by ganciclovir therapy died of multiple organ dysfunction syndrome. Conclusions The diagnosis of ventilator-associated CMV pneumonia should not be excluded in intensive care patients, even those without acquired immunodeficiency syndrome, hematologic malignancy, or immunosuppressive agents on admission.

Open-lung Biopsy in Patients with Acute Respiratory Distress Syndrome

Background It has been suggested that fibrosis present during the fibroproliferative phase of acute respiratory distress syndrome (ARDS) can be treated by corticosteroids. However, neither clinical nor microbiologic criteria permit differentiation of this fibroproliferative phase from a nosocomial pneumonia. The aim of this observational case series was to evaluate the safety and utility of open‐lung biopsy (OLB) performed in patients receiving ventilatory support who had persistent ARDS despite negative bacterial cultures. Methods During a 4‐yr period, 37 OLBs were performed in 36 of 197 patients receiving ventilatory support who had ARDS. The severity of ARDS was assessed by a lung injury score of 3.1 +/‐ 0.4 (mean +/‐ SD) and a median ratio of the partial pressure of oxygen (PaO2) to the fraction of inspired oxygen (FiO2) of 118 mmHg. Histologic examination; bacterial, fungal, and acid‐fast staining; and cultures of the tissue sample were performed. Results Fibrosis was present in only 41% of the lung specimens obtained by OLB. Only six patients received corticosteroids (17%). In 9 of the 15 patients with fibrosis, cytomegalovirus pneumonia precluded the use of corticosteroids. Histologic cytomegalovirus pneumonia was diagnosed in 18 cases. Histologic bacterial or mycobacterial pneumonia was diagnosed in five cases. No significant change in arterial blood gases was noted as linked to the biopsy procedure except an increase of the PaO2 /FI O2 ratio. One pneumothorax was diagnosed on a chest roentgenogram 12 h after OLB. Only one patient required blood transfusion during the 48‐h period after OLB (for an hemothorax). Five patients had moderate air leaks from operative chest tubes for 2–10 days. Conclusions Open lung biopsy appeared to be a useful and acceptably safe diagnostic technique in patients with ARDS. It permitted the diagnosis of unexpected cytomegalovirus pneumonia.

Active cytomegalovirus infection is common in mechanically ventilated medical intensive care unit patients.

Objective:To assess the incidence, risk factors, and outcome of active cytomegalovirus (CMV) infection in nonimmunosuppressed intensive care unit (ICU) patients. Design:Prospective epidemiologic study. Setting:A medical ICU in a university hospital. Patients:Two hundred forty-two nonimmunosuppressed ICU patients mechanically ventilated for ≥2 days. Interventions:Routine pp65 antigenemia and serology for CMV were performed at admission, and then weekly. Bronchoalveolar lavage viral cultures were done when pneumonia was suspected. Measurements and Main Results:Thirty-nine of the 242 ICU patients (16.1%, confidence interval 11.5% to 20.7%) developed an active CMV infection, as diagnosed by positive antigenemia (85%) and/or positive rapid viral culture in bronchoalveolar lavage (26%). Antiviral treatment was initiated in 21 (54%) patients. ICU mortality (54% vs. 37%, p = 0.082) and in-hospital mortality (59% vs. 41%, p = 0.058) were increased in patients with active CMV infection, as compared with those without active CMV infection. Active CMV infection and Simplified Acute Physiology Score II at admission were associated with ICU death on multivariate analysis. The patients with active CMV infection had longer mechanical ventilation and longer ICU stay and were significantly more prone to developing bacterial nosocomial infections (p < 0.001). Logistic regression analysis showed that prior admission to other wards (p = 0.043; odds ratio [OR], 2.49), blood transfusions (p = 0.04; OR, 3.31), enteral feeding (p = 0.005; OR, 3.00), recent corticosteroid use before ICU admission (p = 0.08; OR, 2.26), and age (p = 0.07; OR, 1.026) were associated with the occurrence of active CMV infection. Conclusions:Active CMV infection is common among previously healthy patients under mechanical ventilation in a medical ICU. Further studies are needed to evaluate the role of antiviral treatments to reduce both the incidence and the outcome impact of active CMV infection.

Lack of nasal carriage of novel corona virus (HCoV‐EMC) in French Hajj pilgrims returning from the Hajj 2012, despite a high rate of respiratory symptoms

Abstract A cohort of 154 French Hajj pilgrims participating in the 2012 Hajj were systematically sampled with nasal swabs prior to returning to France, and screened for the novel HCoV-EMC coronavirus by two real-time RT-PCR assays. Despite a high rate of respiratory symptoms (83.4%), including 41.0% influenza-like illness, no case of HCoV-EMC infection was detected. Despite the fact that zoonotic transmission was suspected in the first few cases, a recent family cluster in the Kingdom of Saudi Arabia suggests that the virus might show at least limited spread from person to person, which justifies continuing epidemiological surveillance.

Nosocomial transmission of hepatitis C virus in haemodialysis patients.

A systematic virological follow‐up of 114 haemodialysis patients treated in the same unit showed that 37, including 17 PCR positive patients, were seropositive for hepatitis C virus (HCV). Type 1b HCV was detected in 10 patients and was much more frequent in this population than in the whole population of patients treated in the hepatogastroenterology departments in southeastern France. The E1/E2 genomic region of seven type 1b HCV strains was sequenced. In four patients, a similar strain was detected in both the E1 variable region and the E2 hypervariable region (HVR1). In addition, two of these four patients were seronegative and PCR negative at the beginning of the study and had not been transfused or transplanted during this period. A phylogenetic tree was drawn which confirmed that these strains were very similar and showed that HCV was transmitted via the nosocomial pathway in this haemodialysis unit.

Likely correlation between sources of information and acceptability of A/H1N1 swine-origin influenza virus vaccine in Marseille, France.

Background In France, there was a reluctance to accept vaccination against the A/H1N1 pandemic influenza virus despite government recommendation and investment in the vaccine programme. Methods and Findings We examined the willingness of different populations to accept A/H1N1vaccination (i) in a French hospital among 3315 employees immunized either by in-house medical personnel or mobile teams of MDs and (ii) in a shelter housing 250 homeless persons. Google was used to assess the volume of enquiries concerning incidence of influenza. We analyzed the information on vaccination provided by Google, the website of the major French newspapers, and PubMed. Two trust Surveys were used to assess public opinion on the trustworthiness of people in different professions. Paramedics were significantly more reluctant to accept immunisation than qualified medical staff. Acceptance was significantly increased when recommended directly by MDs. Anecdotal cases of directly observed severe infections were followed by enhanced acceptance of paramedical staff. Scientific literature was significantly more in favour of vaccination than Google and French newspaper websites. In the case of the newspaper websites, information correlated with their recognised political reputations, although they would presumably claim independence from political bias. The Trust Surveys showed that politicians were highly distrusted in contrast with doctors and pharmacists who were considered much more trustworthy. Conclusions The low uptake of the vaccine could reflect failure to convey high quality medical information and advice relating to the benefits of being vaccinated. We believe that the media and internet contributed to this problem by raising concerns within the general population and that failure to involve GPs in the control programme may have been a mistake. GPs are highly regarded by the public and can provide face-to-face professional advice and information. The top-down strategy of vaccine programme management and information delivered by the Ministry of Health could have aggravated the problem, because the general population does not always trust politicians.

Prospective investigation of a large outbreak of meningitis due to echovirus 30 during summer 2000 in marseilles, france.

Abstract: Enteroviruses (EVs) are responsible for an array of clinical diseases affecting different systems of the organism. Many cases are asymptomatic; the most severe clinical syndromes caused by EVs are due to infection of the central nervous system and present as aseptic meningitis or encephalitis. We report here a large outbreak of enteroviral meningitis that spread in Marseilles, France, during the year 2000. The dominant strain of the outbreak was genetically identified as a human echovirus 30. The study was conducted prospectively from May to December 2000, with an investigative protocol recording epidemiologic, clinical, and laboratory data. A total of 250 patients with febrile neurologic manifestations were included between May 15 and December 30, 2000. A total of 195 cerebrospinal fluid (CSF) samples, 114 throat swabs, and 85 stool specimens were processed through viral culture and resulted in respectively 117 (60%), 61 (54%), and 58 (68%) cultures positive for EV; 69/106 (65%) CSF samples tested positive for the presence of EV RNA. None of the throat swab cultures but 5 of the stool cultures in control patients were positive. One hundred thirty-nine (55.6%) patients were considered confirmed cases because they had positive culture or reverse transcription polymerase chain reaction (RT-PCR) in CSF, and 38 (15.2%) patients were considered probable cases because they had a positive throat and/or stool culture and a negative (or not performed) procedure in CSF. The 177 confirmed and probable cases were not significantly different from the remaining 73 patients in terms of age distribution and epidemiologic, clinical, and biologic characteristics. The median age was 18.4 years (range, 15 d to 84 yr), and 92% of patients were younger than 40 years old. The male:female sex ratio was 1.8:1. We found no evidence of cases spread in nosocomial, household, or institutional settings, or limited community spread. All patients were immunocompetent except 4 adults. Meningoencephalitis represented 5.6% of cases. All but 3 of the 177 patients had a good outcome without sequelae. Two immunocompetent adults with meningoencephalitis had neurologic sequelae and an immunosuppressed adult had a fatal outcome. Upper respiratory symptoms were noted in 18.5% of patients, diarrhea in 11.5%, various types of rash in 4.5%, and myalgia in 3.8%. In CSF, white cell count was elevated in 90% of cases, with a percentage of neutrophils >50% in 55% of cases. Protein level was increased in 43% of cases. In blood, C-reactive protein was elevated in 67% of cases. Other blood parameters were unremarkable. Clinical and laboratory features did not differ from those related to other pathogens that caused meningitis and meningoencephalitis. Hence, unnecessary treatment for other infections is frequently instituted during EV infections. Virologic diagnosis is important to distinguish between EV and other treatable bacterial and viral diseases. Abbreviations: CSF = cerebrospinal fluid; ECV-30 = Echovirus 30; EV = enterovirus.

Improved current methods for amplification of DNA from routinely processed liver tissue by PCR.

With both a classic DNA preparation protocol (including removal of paraffin wax and protein digestion) and a DNA extraction protocol with Chelex 100, the hepatitis B virus genome was searched for using the polymerase chain reaction (PCR) in 30 samples of paraffin wax embedded liver tissue from patients with chronic hepatitis. The classic protocol was more sensitive than the rapid Chelex 100 procedure (10 v six positive samples). A third protocol, including removal of paraffin wax, protein digestion, and Chelex 100 treatment of the digestion solution before PCR, was more sensitive than the others (16 positive samples). It is concluded that it could therefore be helpful for PCR analysis of paraffin wax embedded liver tissue.