Iron as an emerging therapeutic target in critically ill patients

The multiple roles of iron in the body have been known for decades, particularly its involvement in iron overload diseases such as hemochromatosis. More recently, compelling evidence has emerged regarding the critical role of non-transferrin bound iron (NTBI), also known as catalytic iron, in the care of critically ill patients in intensive care units (ICUs). These trace amounts of iron constitute a small percentage of the serum iron, yet they are heavily implicated in the exacerbation of diseases, primarily by catalyzing the formation of reactive oxygen species, which promote oxidative stress. Additionally, catalytic iron activates macrophages and facilitates the growth of pathogens. This review aims to shed light on this underappreciated phenomenon and explore the various common sources of NTBI in ICU patients, which lead to transient iron dysregulation during acute phases of disease. Iron serves as the linchpin of a vicious cycle in many ICU pathologies that are often multifactorial. The clinical evidence showing its detrimental impact on patient outcomes will be outlined in the major ICU pathologies. Finally, different therapeutic strategies will be reviewed, including the targeting of proteins involved in iron metabolism, conventional chelation therapy, and the combination of renal replacement therapy with chelation therapy.

Design of a water-soluble chitosan-based polymer with antioxidant and chelating properties for labile iron extraction

Loosely bound iron, due to its contribution to oxidative stress and inflammation, has become an important therapeutic target for many diseases. A water-soluble chitosan-based polymer exhibiting both antioxidant and chelating properties due to the dual functionalization with DOTAGA and DFO has been developed to extract this iron therefore preventing its catalytic production of reactive oxygen species. This functionalized chitosan was shown to have stronger antioxidant properties compared to conventional chitosan, improved iron chelating properties compared to the clinical therapy, deferiprone, and provided promising results for its application and improved metal extraction within a conventional 4 h hemodialysis session with bovine plasma.

Twice- or Once-Daily Dosing of Direct Oral Anticoagulants, a systematic review and meta-analysis

AIM

The direct oral anticoagulants (DOAC) have similar half-lives, but the dosing regimen varies between once daily (QD) or twice daily (BID). For some prescribers, the QD regimen improves compliance. Others prefer BID regimens to promote better stability of plasma concentrations, particularly in the event of missed doses. Limited level of evidence provides guidance about the best treatment strategy. The purpose of this study was to compare the treatment effect of QD vs. BID administration of DOACs in major orthopedic surgery (MOS), non-valvular atrial fibrillation (NVAF), venous thromboembolism (VTE), and acute coronary syndrome (ACS).

METHODS

We conducted a systematic review up to April 2020. We included phase II clinical trials comparing DOAC QD vs BID with same daily dose. We extracted data for the occurrence of major thrombosis (proximal deep vein thrombosis, pulmonary embolism, myocardial infarction, ischemic stroke) and major hemorrhage (ISTH criteria and recommendations of the European Medicines Agency for surgical patients). Relative risks (RR) were combined using a fixed and random effects weighted meta-analysis.

RESULTS

Twelve randomized, controlled, phase II trials were included (10,716 patients), representing 24 dosing regimen comparisons of apixaban, darexaban, edoxaban, rivaroxaban, letaxaban, and dabigatran. There was no difference for major thrombotic event (RR_BID/QD = 1.06, 95%IC 0.86-1.30) nor for major bleeding (RR_BID/QD = 1.02, 95%IC 0.84-1.23) between the BID vs QD regimens, without heterogeneity (I² = 0%).

CONCLUSION

Our study does not support a global difference in term of efficacy and safety of the BID and QD regimens of DOAC in MOS, NVAF, VTE and ACS.

Acute renal and splenic infarctions: a review

BACKGROUND

Renal and splenic infarctions are close entities, with few data concerning their clinical, biological and radiological features.

AIM

The aim of this study was to compare the clinical presentations, etiologies and outcomes of acute renal infarctions (RI) and splenic infarctions (SI).

DESIGN

A retrospective multicentric cohort study included patients of the 6 university hospitals in Lyon with RI, SI, or associated RI-SI infarctions was conducted.

METHODS

All consecutive cases diagnosed by CT imaging, between January 2013 and October 2016, were included. The exclusion criteria were causes of infarction that did not require additional investigations.

RESULTS

A total of 161 patients were selected for analysis: 34 patients with RI, 104 patients with SI and 23 patients with both RI-SI. Mean ± SD age of patients was 63.2 ± 16.6 years; 59.6% were male. Only 5/161 (3.1%) were healthy prior to the event. The main symptoms were diffuse abdominal pain (26.4%), followed by nausea/vomiting (18.3%) and fever (16.4%).The causes of RI or SI varied significantly within the three groups. Hypercoagulable state was associated with SI, and embolic disease and arterial injury were associated with RI. Extensive (i.e.>2/3 of organ volume) (OR 6.22, 95%CI 2.0119.22) and bilateral infarctions (OR 15.05, 95%CI 1.79-126.78) were significantly associated with hemodynamic shocks. The survival at 1 month follow-up did not significantly differ between the three groups.

CONCLUSION

Acute RI and SI are heterogenous entities in regards to their clinical presentation, etiology, associated venous or arterial thrombosis, but prognoses were not different at short term follow-up.

[Doppler ultrasonography of the renal artery: Guidelines and predictive factors for the presence of a tight stenosis. Retrospective analysis of 450 consecutive examinations]

Duplex ultrasonography screening for renal artery stenosis has been the object of guidelines published by four societies designed to optimize the cost-effectiveness of the examination.

OBJECTIVES

To determine how well guideline indications for ultrasonography matched with requests and results in our university hospital; to determine whether compliance with guidelines was predictive of renal artery stenosis; to identify guidelines predictive of presence of stenosis; and to determine whether other predictive factors can be recognized.

MATERIAL AND METHODS

Requests and results of 450 Duplex ultrasonography examinations of the renal arteries performed from January 1st 2014 to December 31st 2015 were compared with published guidelines.

RESULTS

At least one guideline indication was identified for 212 of the 450 examinations performed (47.1%). Among these examinations, renal artery stenosis≥70% was identified in 18 patients (8.0%). No case of stenosis was identified during examinations performed outside guideline indications. Factors predictive of stenosis were: compliance with guidelines (OR=21.86 [2.88; 165.8]). Predictive guidelines were: resistant hypertension in spite of appropriate treatment (OR=3.85, [1.44; 10.33], P=0.011), accelerated hypertension (OR=7.30, [1.40; 37.99], P=0.049), sudden unexplained pulmonary edema (OR=7.30, [1.40; 37.99], P=0.049), unexplained renal insufficiency (OR=3.58, [1.37; 9.37], P=0.011), unexplained renal hypotrophy (OR=16.69, [4.38; 63.69], P<0.001), renal asymmetry (OR=4.32, [1.45; 12.85], P<0.016). No other factor was predictive of renal stenosis. These examinations had therapeutic consequences in only 50% of patients.

CONCLUSION

This study confirms the relevance of published guidelines. The diagnostic-effectiveness of Duplex ultrasonography examinations to search for renal artery stenosis depends upon compliance with these guidelines.

The Clinical Relevance of Antifibrillarin (anti-U3-RNP) Autoantibodies in Systemic Sclerosis

Systemic sclerosis (SSc) is a heterogeneous autoimmune disease associated with several antinuclear autoantibodies useful to diagnosis and prognosis. The aim of the present multicentric study was to determine the clinical relevance of antifibrillarin autoantibodies (AFA) in patients with SSc. The clinical features of 37 patients with SSc positive for AFA (AFA+) and 139 SSc patients without AFA (AFA-) were collected retrospectively from medical records to enable a comparison between AFA- and AFA+ patients. Antifibrillarin autoantibodies were screened by an indirect immunofluorescence technique using HEp2 cells and identified by an in-house Western blot technique and/or an EliA test. Comparing AFA+ and AFA- patients, AFA+ patients were significantly younger at disease onset (36.9 versus 42.9; P = 0.02), more frequently male (P = 0.02) and of Afro-Caribbean descent (65% versus 7.7%; P < 0.001). At diagnosis, the Rodnan skin score evaluating the cutaneous manifestations was higher (13.3 versus 8.7; P = 0.01) and myositis was also more common in the AFA+ group (31.4% versus 12.2%; P < 0.01). Patients with AFA+ were not associated with diffuse cutaneous SSc or with lung involvement and no difference in survival was observed. Antifibrillarin autoantibodies are associated with patients of Afro-Caribbean origin and can identify patients with SSc who are younger at disease onset and display a higher prevalence of myositis.

Prevalence of fecal incontinence in a cohort of systemic sclerosis patients within a regional referral network

Background

The prevalence of gastrointestinal involvement in systemic sclerosis is higher than 75%. The estimated prevalence of fecal incontinence varies from 22% to 77%, but suffers from recruitment bias and patient reluctance. Our goal was to evaluate the prevalence of fecal incontinence in systemic sclerosis, and to identify associated risk factors.

Methods

Patients were recruited in the referral systemic sclerosis network of the Lyon University Hospitals, using self-administered questionnaires including constipation, fecal incontinence and Bristol Stool scales, quality of life, anxiety and depression. The cohort was compared with the historical ORALIA cohort that established the prevalence of fecal incontinence in the general population of the Rhône-Alpes region (France).

Results

Seventy-seven patients were included (mean age: 60 years, range: 32-84), and 86% were female. These were compared to 153 ORALIA individuals matched for age and sex. Fecal incontinence was present in 38% of patients and 6% of the general population. A longer duration of systemic sclerosis was the only characteristic associated with fecal incontinence. Abnormal stool consistency was more frequent in patients with fecal incontinence.

Conclusion

Fecal incontinence and abnormal stool consistency are common in systemic sclerosis and should be systematically addressed.

A prognostic score to identify low-risk outpatients with acute deep vein thrombosis in the lower limbs

BACKGROUND

No prior studies have identified which patients with deep vein thrombosis in the lower limbs are at a low risk for adverse events within the first week of therapy.

METHODS

We used data from the Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) to identify patients at low risk for the composite outcome of pulmonary embolism, major bleeding, or death within the first week. We built a prognostic score and compared it with the decision to treat patients at home.

RESULTS

As of December 2013, 15,280 outpatients with deep vein thrombosis had been enrolled. Overall, 5164 patients (34%) were treated at home. Of these, 12 (0.23%) had pulmonary embolism, 8 (0.15%) bled, and 4 (0.08%) died. On multivariable analysis, chronic heart failure, recent immobility, recent bleeding, cancer, renal insufficiency, and abnormal platelet count independently predicted the risk for the composite outcome. Among 11,430 patients (75%) considered to be at low risk, 15 (0.13%) suffered pulmonary embolism, 22 (0.19%) bled, and 8 (0.07%) died. The C-statistic was 0.61 (95% confidence interval [CI], 0.57-0.65) for the decision to treat patients at home and 0.76 (95% CI, 0.72-0.79) for the score (P = .003). Net reclassification improvement was 41% (P < .001). Integrated discrimination improvement was 0.034 for the score and 0.015 for the clinical decision (P < .001).

CONCLUSIONS

Using 6 easily available variables, we identified outpatients with deep vein thrombosis at low risk for adverse events within the first week. These data may help to safely treat more patients at home. This score, however, should be validated.

Gonococcemia mimicking a lupus flare in a young woman

Gonorrhea is a common sexually transmitted infection, which can present as the ‘arthritis-dermatitis syndrome’. Patients with systemic lupus erythematosus often develop disseminated neisserial infections, because of inherited and acquired complement deficiencies. Neisserial infection, and particularly gonococcemia, can mimic a lupus flare. We report one case of gonococcemia presenting as acral papulo-vesiculous lesions of the digits in a young woman with lupus.

Endothelial progenitor cell-derived microvesicles improve neovascularization in a murine model of hindlimb ischemia

Paracrine mediators released from endothelial progenitor cells (EPCs) have been implicated in neoangiogenesis following ischemia. Recently, we demonstrated that microvesicles (MVs) derived from EPCs are able to activate an angiogenic program in quiescent endothelial cells by a horizontal transfer of RNA. In this study we aim to investigate whether EPC-derived MVs are able to induce neoangiogenesis and to enhance recovery in a murine model of hindlimb ischemia. Hindlimb ischemia was induced in severe combined immunodeficient (SCID) mice by ligation and resection of the left femoral artery and mice were treated with EPC-derived MVs (MVs), RNase-inactivated MVs (RnaseMVs), fibroblast-derived MVs or vehicle alone as control (CTL). Since MVs contained the angiogenic miR-126 and miR-296, we evaluated whether microRNAs may account for the angiogenic activities by treating mice with MVs obtained from DICER-knock-down EPC (DICER-MVs). The limb perfusion evaluated by laserdoppler analysis demonstrated that MVs significantly enhanced perfusion in respect to CTL (0.50±0.08 vs 0.39±0.03, p<0.05). After 7 days, immunohistochemical analyses on the gastrocnemius muscle of the ischemic hindlimb showed that MVs but not fibroblast-MVs significantly increased the capillary density in respect to CTL (MVs vs CTL: 24.7±10.3 vs 13.5±6, p<0.0001) and (fibroblast-MVs vs CTL: 10.2±3.4 vs 13.5±6, ns); RNaseMVs and DICER-MVs significantly reduced the effect of MVs (RNaseMVs vs CTL: 15.7±4.1 vs 13.5±6, ns) (MVs vs DICER-MVs 24.7±10.3 vs 18.1±5.8, p <0.05), suggesting a role of RNAs shuttled by MVs. Morphometric analysis confirmed that MVs enhanced limb perfusion and reduced injury. The results of the present study indicate that treatment with EPC-derived MVs improves neovascularization and favors regeneration in severe hindlimb ischemia induced in SCID mice. This suggests a possible use of EPCs-derived MVs for treatment of peripheral arterial disease.

Proximal row carpectomy: Is early postoperative mobilisation the right rehabilitation protocol?

PURPOSE OF THE STUDY

To determine the feasibility and interest of an early rehabilitation protocol with no initial immobilisation after proximal row carpectomy.

MATERIAL AND METHODS

Thirteen patients were included in this retrospective study. Range of motion (ROM) and wrist strength (grip strength and grasp strength) were evaluated 3 and 6 weeks after surgery on the both wrists (operated and non-operated). Postoperatively, patients had no immobilisation of the wrist, and began a rehabilitation program immediately after surgery in the department of Physical Therapy and Rehabilitation under multidisciplinary team supervision. The same surgical technique was used for all patients by the same surgeon.

RESULTS

Six weeks after PRC, there was a 25-51% deficit in passive ROM and 54-64% deficit in active ROM compared to the corresponding non-operated wrist. Six weeks after PRC, mean overall grip strength was nearly 55% and Jamar dynamometer grip strength was 51% of the contralateral side.

DISCUSSION

This study shows that immediate immobilisation following PRC is unnecessary, and that early rehabilitation is of the essence. Early rehabilitation could reduce the delay necessary to recover range of motion and strength, and probably the time to return to work.

LEVEL OF EVIDENCE

Level 4, prospective cohort study.

African-American and caucasian female cancer patients’ cancer and treatment information needs and preferred information sources

9073

Background: Patients need information to maximize access to appropriate care, make informed decisions about treatment and communicate with their physicians and other healthcare providers. This study examined information needs related to cancer care and preferred information sources across ethnicities. Methods: A cross-sectional telephone survey was conducted with a random sample of 107 African-American and Caucasian female cancer patients from a university-affiliated cancer clinic. Descriptive analyses characterize patient demographics and information preferences. Multiple logistic regression tested variations in preferences by ethnicity. Results: There were significant differences in what African-American and Caucasian cancer patients considered their primary sources of information about their cancer and treatment. More African-Americans (36%) than Caucasians (9%) said they go to healthcare providers other than their physicians (e.g., nurses, nursing assistants, p=0.002) and use the library (14% vs. 7%) for information about their disease and treatment (p=0.002). Caucasian patients more often said they go to physicians (61% vs. 40%, p<0.01) or the internet (23% vs. 10%, p=0.04) for their information. More African-Americans (84%) than Caucasians (59%) rated information about counseling for emotional support as extremely important (p<0.01) and rated information about issues such as transportation and legal advice as extremely important (75% vs. 55%, p=0.05). There were no differences between ethnicities in desire for information about disease, treatment, side effects, and chances of getting better. Conclusions: All patients desired accurate and comprehensive information about their disease, prognosis and treatment. Significant differences were found between African-Americans and Caucasians in type and means of information. African-American patients were more likely to obtain information from providers other than physicians, and Caucasians were more likely to use the internet. These findings have implications for training professionals and developing programs to provide information to patients about their cancer treatment.

No significant financial relationships to disclose.

Perceptions and beliefs related to cancer care among African-American and Caucasian patients

8518

Background: Without a clear understanding of belief systems and cultures it is not possible to provide optimal care to ethnic minority individuals. This study examined perceptions and beliefs of African-Americans and Caucasians related to cancer care. Methods: Eleven focus groups were conducted with 39 African-American and Caucasian cancer patients recruited from a university-affiliated cancer clinic, using established qualitative methodology. Data analysis included whole group analysis with a team of 4 researchers. Atlas Ti software was used to validate the coding and establish Intra-rater and inter-rater reliability. Results: There were consistent themes across both ethnicities that related to reactions to diagnosis, wanting certain types of information, wanting to stay positive, coping, and social connectivity. Cultural differences were also apparent (Table). Differences based on ethnicity Conclusions: African-American participants described increased religiosity and faith after diagnosis and were more likely than Caucasian participants to seek information about cancer issues from friends, family, and community. There also were differences in perceptions of how health care providers demonstrate care for patients. Findings have implications for training professionals regarding ways patients seek information, the role of spirituality and religion in care and behaviors that patients perceive as indicative of caring.

[Table: see text]

No significant financial relationships to disclose.

Supportive and unsupportive behaviors of friends and families as experienced by cancer patients

18625

Background: Interpersonal support can help individuals manage stressors associated with cancer diagnosis and treatment. This study reveals cancer patients’ experiences with supportive and unsupportive behaviors of friends and families. Insufficient or inappropriate social support can negatively impact coping, quality of life and other patient outcomes. Methods: Eleven focus groups were conducted with 39 African-American and Caucasian cancer patients recruited from a university-affiliated cancer clinic, using established qualitative methodology. Data analysis included whole group analysis with a team of 4 researchers. Atlas Ti software was used to validate coding and establish intra-rater and inter-rater reliability. Results: Supportive behaviors included practical assistance (e.g., providing meals), family providing housing and daily care, family/friends who listen, prayer, and a social context that demonstrates positive attitudes. Unsupportive behavior included limitations of independence and withdrawal from patients due to fear or discomfort, as well as having to provide emotional support to family or friends. African-American participants were more likely than Caucasian participants to report family or community resources available for daily care and expressed greater concern about limitations to independence. Conclusions: Findings have implications for interventions to improve the quality of support provided to cancer patients from their caregivers and communities. Results can be used to inform family, friends and caregivers about the types of support valued by patients.

[Table: see text]

No significant financial relationships to disclose.

Medical implications of employee assistance programmes

The development of employee assistance programmes (EAPs) has significant implications for doctors, especially general practitioners and psychiatrists. This paper discusses the importance of training counsellors to detect serious psychological disorders among people who use an EAP service and the need for clinicians to accept referrals of those users who are identified as being in need of further medical treatment.

[Constrictive bronchiolitis obliterans. Apropos of a case]

INTRODUCTION

Constrictive bronchiolitis obliterans is defined histologically as obliteration of the lumina of bronchioles by inflammatory tissue elements and progressive destruction of bronchioles, eventually replaced by fibrotic tissue. Most of the cases, which are not associated with either solid organ or bone marrow transplantation, occur in the development of rheumatoid arthritis.

EXEGESIS

We present the case of a 73-year-old woman who developed severe constrictive bronchiolitis obliterans without readily identifiable cause, rapidly fatal despite corticosteroid therapy. The patient had antinuclear antibodies (titer 1/1024) and antiphospholipid antibodies, but there was no anti-DNA, anti-ENA or anti-beta 2GPI antibodies. Tests for rheumatoid factor were negative. Cryoglobulinemia was present (monoclonal IgM Kappa).

CONCLUSION

In this case, constrictive bronchiolitis obliterans was associated with serologic abnormalities and cryoglobulinemia. However, were was no clinical evidence of connective tissue disease.

In-line Nd:YAG resonator using self-pumped phase conjugation in Cr(4+):YAG

We report the operation of an in-line Nd:YAG resonator using self-pumped phase conjugation in Cr(4+): YAG at lambda=1.064microm in the nanosecond regime. The output beam has a high-quality diffraction-limited TEM(00) mode and a pulse shape of ~15ns , showing the self- Q -switching ability of the resonator. A maximum extraction of 18mJ and a maximum reflectivity of 2.0 are measured. A transient model provides insight into the energy characteristics and the dynamics of such an in-line resonator.

[Association of Biermer's anemia and gastric carcinoid tumors]

BACKGROUND

The occurrence of gastric carcinoid tumors during the cure of pernicious anemia has been reported in the literature. Concerning a new case, we review physiopathological data of this infrequent association.

CASE REPORT

We report the case of a 47-year-old women with pernicious anemia in which gastroscopy found two small tumors developed from enterochromaffin-like cells.

CONCLUSION

These tumors are usually latent and developed from enterochromaffin-like cells. The pathologic and histologic diagnosis is based on positive chromogranin A immunomarking. The physiopathological mechanism studies are in favour of the predominant part of hypergastrinemia following achlorhydria. Usually, evolution is benign and surgical or endoscopic resection recommended.