Patrick Devos

Improvement in process of care and outcome in patients requiring intensive care unit admission for community acquired pneumonia

BackgroundThe present study was performed to assess the prognosis of patients admitted to the intensive care unit (ICU) for community acquired pneumonia (CAP) after implementation of new processes of care.MethodsTwo groups of patients with CAP were admitted to a 16-bed multidisciplinary ICU in an urban teaching hospital during two different periods: the years 1995–2000, corresponding to the historical group; and 2005–2010, corresponding to the intervention group. New therapeutic procedures were implemented during the period 2005–2010. These procedures included a sepsis management bundle derived from the Surviving Sepsis Campaign, use of a third-generation cephalosporin and levofloxacin as the initial empirical antimicrobial regimen, and noninvasive mechanical ventilation following extubation.ResultsA total of 317 patients were studied: 142 (44.8%) during the historical period and 175 (55.2%) during the intervention period. Sequential Organ Failure Assessment scores were higher in patients in the intervention group (7.2 ± 3.7 vs 6.2 ± 2.8; p=0.008). Mortality changed significantly between the two studied periods, decreasing from 43.6% in the historical group to 30.9% in the intervention group (p < 0.02). A restrictive transfusion strategy, use of systematic postextubation noninvasive mechanical ventilation in patients with severe chronic respiratory or cardiac failure patients, less frequent use of dobutamine and/or epinephrine in patients with sepsis or septic shock, and delivery of a third-generation cephalosporin associated with levofloxacin as empirical antimicrobial therapy were independently associated with better outcomes.ConclusionPositive outcomes in ICU patients with CAP have significantly increased in our ICU in recent years. Many new interventions have contributed to this improvement.

Pulmonary perfusion scintigraphy: a tool to detect the presence of pulmonary artery involvement in Takayasu's arteritis.

OBJECTIVE Takayasu arteritis (TA) is a large-vessel vasculitis that can also involve pulmonary arteries. The aim of this study was to evaluate the frequency of pulmonary artery involvement in TA patients using pulmonary perfusion scintigraphy (PPS) and to determine the characteristics of patients with pulmonary artery involvement. METHODS Twenty-one patients classified as having TA underwent PPS. PPS positivity was defined as the presence of perfusion defects with normal ventilation. TA diagnosis was assessed using American College of Rheumatology (ACR) and/or Ishikawas modified criteria. RESULTS Twenty-one patients (median age 36 years [range; 21-78]; 18 females) were analyzed. PPS was positive in 12 (57%) patients. Pulmonary symptoms were present in 4/12 patients with positive PPS, but none in patients with negative PPS. Among the 12 patients with positive PPS, eight patients (67%) were asymptomatic with regard to pulmonary involvement. No difference was noted between patients with positive and negative PPS with respect to general characteristics, vascular involvement, biological parameters or treatment regimen. PPS sensitivity was 100%, specificity at 53% and predictive negative value at 100% in patients with TA relative to the presence of pulmonary symptoms. CONCLUSION Although frequent, pulmonary artery involvement in TA is often asymptomatic. Its systematic detection by PPS could be valuable in the diagnosis of TA.

Grade 2 meningioma and radiosurgery

OBJECT World Health Organization Grade 2 meningiomas are aggressive tumors associated with a high recurrence rate leading to repeated surgical procedures, which can seriously worsen a patients neurological status. Although radiosurgery is an increasingly popular technique, its role in the management of Grade 2 meningiomas has yet to be defined. In this study the authors aimed to evaluate radiosurgery in achieving control of proven tumor progression occurring after resection of Grade 2 meningioma. METHODS This retrospective study included consecutive patients who, between 2000 and 2012, had undergone radiosurgery for radiologically proven progression of a previously surgically treated Grade 2 meningioma. RESULTS Twenty-seven patients were eligible for analysis. There were 9 men and 18 women with a mean age of 59 years. The mean radiation dose was 15.2 Gy (range 12-21 Gy), and the mean target volume was 5.4 cm(3) (range 0.194-14.2 cm(3)). Thirty-four radiosurgical procedures were performed in the 27 patients. The mean progression-free survival after radiosurgery was 32.4 months among those with progression in a target irradiated volume and 26.4 months among those with progression in any intracranial meninges. With a mean follow-up of 56.4 months (range 12-108 months), the 12-, 24-, and 36-month actuarial local control rates for all patients were 75%, 52%, and 40%, respectively, and the regional control rates were 75%, 48%, and 33%. A single case of transient hemiparesis completely resolved without sequelae. CONCLUSIONS Radiosurgery appears to be a safe and effective treatment for the local control of delayed progression after resection of a Grade 2 meningioma. Higher radiation doses similar to those applied for malignant tumors should be recommended when possible.

Hospital-Acquired Pneumonia in Critically Ill Patients

AbstractStudy objectives: To identify, in patients experiencing hospital-acquired pneumonia (HAP), prognostic factors present at disease onset and build an algorithm capable of stratifying mortality risk upon HAP onset. Design: Observational cohort from January 1994 to December 2001. Setting: One intensive care unit (ICU) from a university-affiliated, urban teaching hospital. Patients: All consecutive patients exhibiting bacteriologically documented HAP either on ICU admission or during ICU stay. Interventions: Data collection and multivariate analysis using Chi-Square Automatic Interaction and Detection technique. Results: 168 patients were studied. The overall mean mortality rate was 49.4%. Upon onset of HAP, five independent variables allowed binary stratification of mortality risk. These consisted of underlying diseases (nonfatal versus ultimately and rapidly fatal diseases), Simplified Acute Physiology Score II (less than versus ≥37), platelet count (less than versus ≥150 000/mm3), chest x-ray involvement (1 versus >1 lobe), and PaO2/FiO2 (less than versus ≥167mm Hg). A branching algorithm consisting of these five variables identified patients with HAP at both low (<35%) and high (>75%) risk of mortality. Conclusion: Mortality in ICU patients with HAP may be predicted early, upon onset of HAP, by the cumulative use of prognostic factors in an algorithm.

Parvovirus H-1 induces cytopathic effects in breast carcinoma-derived cultures

Parvovirus H-1 (H-1 PV) preferentially replicates in malignant cells resulting in their death by cytolysis. It has often been considered a potential candidate for use in novel anticancer therapy. To evaluate its potential in a model of natural tumors, we assayed in vitro the effect exerted by H-1 PV on short-term cultures derived from breast tumor samples freshly excised from patients. Our results show that H-1 PV effectively kills tumor-derived cells, whereas normal tissue-derived cells showed no H-1 PV-induced cytopathic effects (CPE). We also determined that the H-1 PV sensitivity (up to 67% sensitive cultures) is related with the quantities of virus assayed. We further examined the expression and phosphorylation state of the parvoviral nonstructural protein 1 (NS1), known to be associated with parvoviruses-induced CPE. Both appear to be impaired in normal tissue-derived cells and resistant cultures. Finally, we show that H-1 PV sensitivity in cultures correlates significantly with higher tumor grades (Nottingham combined histologic grade 2 or 3). This report confirms that H-1 PV can efficiently induce CPE in primary breast tumor cells in vitro. It identifies tumor characteristics representing potential criteria for recruiting patients for clinical evaluation of H-1 PV antitumor effects.

Survival in critically ill patients with acute kidney injury treated with early hemodiafiltration.

PURPOSE Early renal replacement therapy (RRT) initiation should theoretically influence many physiological disorders related to acute kidney injury (AKI). Currently, there is no consensus about RRT timing in intensive care unit (ICU) patients. METHODS We performed a retrospective analysis of all critically ill patients who received RRT in our ICU during a 3 year-period. Our goal was to identify mortality risk factors and if RRT initiation timing had an impact on survival. RRT timing was calculated from the moment the patient was classified as having acute kidney injury in the RIFLE classification. RESULTS A hundred and ten patients received RRT. We identified four independent mortality risk factors: need for mechanical ventilation (OR = 12.82 (1.305 - 125.868, p = 0.0286); RRT initiation timing >16 h (OR = 5.66 (1.954 - 16.351), p = 0.0014); urine output on admission <500 ml/day (OR = 4.52 (1.666 - 12.251), p = 0.003); and SAPS II on admission >70 (OR = 3.45 (1.216 - 9.815), p = 0.02). The RRT initiation =16 h and RRT initiation >16 h groups presented the same baseline characteristics, except for more severe gravity scores and kidney failure in the early RRT group. CONCLUSIONS Early RRT in ICU patients with acute kidney injury or failure was associated with increased survival.

Severe pneumococcal pneumonia: impact of new quinolones on prognosis

BackgroundMost guidelines have been proposing, for more than 15 years, a β-lactam combined with either a quinolone or a macrolide as empirical, first-line therapy of severe community acquired pneumonia (CAP) requiring ICU admission. Our goal was to evaluate the outcome of patients with severe CAP, focusing on the impact of new rather than old fluoroquinolones combined with β-lactam in the empirical antimicrobial treatments.MethodsRetrospective study of consecutive patients admitted in a 16-bed general intensive care unit (ICU), between January 1996 and January 2009, for severe (Pneumonia Severity Index > or = 4) community-acquired pneumonia due to non penicillin-resistant Streptococcus pneumoniae and treated with a β-lactam combined with a fluoroquinolone.ResultsWe included 70 patients of whom 38 received a β-lactam combined with ofloxacin or ciprofloxacin and 32 combined with levofloxacin. Twenty six patients (37.1%) died in the ICU. Three independent factors associated with decreased survival in ICU were identified: septic shock on ICU admission (AOR = 10.6; 95% CI 2.87-39.3; p = 0.0004), age > 70 yrs. (AOR = 4.88; 95% CI 1.41-16.9; p = 0.01) and initial treatment with a β-lactam combined with ofloxacin or ciprofloxacin (AOR = 4.1; 95% CI 1.13-15.13; p = 0.03).ConclusionOur results suggest that, when combined to a β-lactam, levofloxacin is associated with lower mortality than ofloxacin or ciprofloxacin in severe pneumococcal community-acquired pneumonia.

Development and validation of a bedside score to predict early death in cancer of unknown primary patients.

Background We have investigated predictors of 90-day-mortality in a large cohort of non-specific cancer of unknown primary patients. Methods Predictors have been identified by univariate and then logistic regression analysis in a single-center cohort comprising 429 patients (development cohort). We identified four predictors that produced a predictive score that has been applied to an independent multi-institutional cohort of 409 patients (validation cohort). The score was the sum of predictors for each patient (0 to 4). Results The 90-day-mortality-rate was 33 and 26% in both cohorts. Multivariate analysis has identified 4 predictors for 90-day-mortality: performance status>1 (OR = 3.03, p = 0.001), at least one co-morbidity requiring treatment (OR = 2.68, p = 0.004), LDH>1.5×the upper limit of normal (OR = 2.88, p = 0.007) and low albumin or protein levels (OR = 3.05, p = 0.007). In the development cohort, 90-day-mortality-rates were 12.5%, 32% and 64% when the score was [0–1], 2 and [3]–[4], respectively. In the validation cohort, risks were 13%, 25% and 62% according to the same score values. Conclusions We have validated a score that is easily calculated at the beside that estimates the 90-days mortality rate in non-specific CUP patients. This could be helpful to identify patients who would be better served with palliative care rather than aggressive chemotherapy.

Assessing the French Alzheimer plan.

www.thelancet.com Vol 383 May 24, 2014 1805 research projects in social sciences, experimental models and imaging (€8·5 million); education and training facilities (€18·8 million); and national infrastructure (€29 million), mainly in genetics, through the European Alzheimer’s Disease Initiative, cohort studies (the Three Cities and MEMENTO cohorts); and a research neuroimaging platform. The Ministry of Health added €3 million to support the Centres for Early-Onset Alzheimer Disease (in Rouen, Lille, and Paris). This national network recruited 225 families who met the criteria of one confi rmed case of Alzheimer disease in the family with early onset (before 65 years old). The Ministry of Health also provided €17·4 million to support the National Alzheimer Data Bank, based in Nice, which by 2012 had collected standardised information on 403 458 consultations nationwide. In an attempt to assess measures impact, we did a bibliometric evaluation of the potential eff ect of the plan on scientifi c research, 1 year after its end, in 2013. We searched the Web of Science Core Collection for articles on Alzheimer’s disease (Alzheimer in the title, abstract, or keywords), identified the top 10% most-cited original articles in the fi eld worldwide, and analysed the contribution of France and 13 other countries on publications on Alzheimer’s disease (appendix). Between 2007 and 2012, the number of articles in the top most-cited articles increased from 726 to 1117—a 54% increase—globally. The largest participation in the top 10% came from authors in the USA (71%), the UK (17%), and Germany (15%). The participation of French authors in the top 10% mostcited articles increased from 4·8% to 8·4% (a 75% increase)—third largest increase after China (208%) and Spain (188% increase). We also assessed, through a MeSH query, original articles about dementia in the Système d’Interrogation, de Gestion et d’Analyse des Publications Scientifiques (SIGAPS), which collects all French university hospital Assessing the French Alzheimer plan

Salvage intracerebrospinal fluid thiotepa in breast cancer-related leptomeningeal metastases: a retrospective case series.

There is currently a paucity of data on salvage intracerebrospinal fluid (intra-CSF) chemotherapy in leptomeningeal metastases (LM). This report is a single-institution experience with salvage treatment in patients with breast cancer (BC) and LM. This retrospective cohort describes 24 consecutive patients with BC selected for a second-line of treatment for LM. The first line of LM treatment consisted of intra-CSF liposomal cytarabine in all patients combined with systemic therapy in 18 cases and radiotherapy in four cases. Second-line (salvage) treatment utilized intra-CSF thiotepa in all and systemic chemotherapy in nine patients. No patient received CNS-directed radiotherapy. The median Eastern Cooperative Oncology Group performance status at initiation of intra-CSF thiotepa treatment was 3 (range 1–4). The median progression-free survival and median survival following intra-CSF thiotepa was 3.1 months (range 3 days–2 years) and 4.0 months (range 6 days–2.5 years), respectively. The median overall survival from LM diagnosis was 9.5 months (range 1.3 months–2.7 years). No grade 3 or higher toxicity was observed. Recognizing the limits of a retrospective study, intra-CSF thiotepa has an acceptable toxicity profile and appears to be a reasonable option for selected BC patients.