Clues of incomplete reversal of heparin in cardiac surgery

OBJECTIVES

In our center, an unusual rate of patients had abnormalities of hemostasis in immediate postoperative period of cardiac surgery. Our objectives were to identify the cause of these sudden hemostasis abnormalities and to evaluate the performances of point of care coagulation testing.

METHODS

In this prospective and descriptive study, we included 33 consecutive patients undergoing elective cardiac surgery for 1 month. Heparin-induced anticoagulation and calculation of the protamine dose were tested by the Hemostasis Management System Plus device (Medtronic, Minneapolis, MN, USA). Fifteen minutes after the end of the protamine infusion, activated clotting time (ACT), activated partial thromboplastin time and anti Xa activity were measured. In case of unusual clinical bleeding, a Quantra analysis (Stago, HemoSonics LLC, Charlottesville, VA) was added.

RESULTS

Residual antiXa activity >0.2 IU/mL after neutralization was present in 44% of patients. Our investigation concluded incomplete heparin reversal. There was no association between cellular reinfusate and the presence of heparin. The unusual rate of hemostasis abnormalities was explained by a less efficient protamine reversal of heparin. ACT and Clot Time Ratio (CTR, Quantra system) correlated with AntiXa with Spearman's coefficients of 0.85 (p < .0001) and 0.95 (p = .0012), respectively. About ACT, a threshold of 150 seconds had a sensitivity of 85% [58-97] and a specificity of 85% [58-97%] for detection of AntiXa>0.2. For CTR, a threshold of 1.4 had a sensitivity of 67% [30-94] and a specificity of 100% [18-100].

CONCLUSION

The use of point of care coagulation testing is effective in detecting incomplete reversal of heparin.

A Massive Venlafaxine Intoxication: Evolution of Cardiac Toxicity with Venlafaxine and O-Desmethylvenlafaxine Elimination Kinetics: A Grand Round

BACKGROUND

This study presents the case of a 19-year-old woman who attempted suicide by ingesting 11.25 g of venlafaxine (V). She was admitted to the hospital with severe biventricular dysfunction, progressing to cardiac arrest requiring extracorporeal circulatory life support for 11 days. The pharmacokinetics of venlafaxine during impaired cardiac output and the effect of its active metabolite, the O-desmethylvenlafaxine (ODV), are currently not very well understood.

METHODS AND RESULTS

Serum concentrations of V and ODV were monitored twice daily for 3 weeks. The maximum concentrations of venlafaxine and ODV were at 14 hours after ingestion, with 29,180 mcg/L for V and 5399 mcg/L for ODV. Half-lives increased, requiring 2 weeks to eliminate the drug. The left ventricular ejection fraction significantly improved when V + ODV was below 1000 mcg/L and remained altered until the ODV concentrations were lower than 400 mcg/L.

CONCLUSIONS

This report, with complete elimination kinetic of V and ODV in a monodrug intoxication, provides information about the modification of pharmacokinetics in the case of an overdose managed by extracorporeal circulatory life support, the cardiac toxicity of ODV, and the value of the toxic threshold for the active moiety.

Impact of Hypertension on Left Ventricular Geometry and Diastolic Function in Africa: Results from the Population-Based TAnve Health (TAHES) Cohort Study

High blood pressure leads to morphologic changes and functional alterations of the myocardial structure. Transthoracic echocardiography is of great clinical interest to evaluate these alterations, using reference values proposed by the American Society of Echocardiography/European Association of Cardiovascular Imaging, largely based on studies in Caucasian Whites. We aimed to assess the impact of hypertension on echocardiographic parameters in a sub-Saharan African community, using ethnic-specific reference values. This study is part of the TAnve HEalth Study, a population-based prospective cohort study initiated in 2015 in the district of Tanve, Republic of Benin. Hypertension was defined as systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg and/or currently taking antihypertensive medications. All participants had a transthoracic echocardiography. The patterns of diastolic dysfunction and left ventricular (LV) geometry were defined from 486 subjects in the cohort, free from cardiovascular disease, diabetes, and hypertension. Of all participants, 318 (65% women, median age 48 years) had hypertension. Systolic blood pressure correlated significantly (p <0.0001) with LV mass (r = 0.28), wall thickness (r = 0.25), isovolumic relaxation time (r = 0.27), E/A ratio (r = -0.35), lateral e' velocity (r= -0.41), and E/E' ratio (r = 0.39). Ventricular geometry was normal in only 22% of participants with hypertension when using the American Society of Echocardiography/European Association of Cardiovascular Imaging reference values, versus 69% with ethnic-specific reference ranges. The severity of hypertension was associated with ventricular geometry abnormalities. The prevalence of diastolic dysfunction was 14.5% (confidence interval 10.6% to 18.4%), including relaxation impairment (9%) and pseudonormal pattern (6%). Thus, correct assessment of the repercussions of hypertension on LV geometry in Black Africans requires ethnic-specific reference values.

Normal reference values of cardiac chamber sizes and functional parameters in a beninese community population: the TAHES study

Reported ranges of normal values for echocardiographic measurements are mostly issued from studies performed in Caucasians. This study is a part of TAHES, a population-based prospective cohort study in Benin and aims to establish normal reference values for echocardiographic cardiac chambers dimensions and Doppler parameters in a Sub-Saharan African population. We included 486 healthy (non-diabetic, non-obese and normotensive) individuals (202 men and 284 women, age 37[30-47] years, BSA 1.58 (1.47-1.67) m2). End-diastolic interventricular septal wall thickness, left ventricular (LV) internal diameter, posterior wall thicknesses, and systolic LV internal diameter were respectively at 10[9-12], 45[43-49], 9[8-11], 29[26-34] mm for male and 9[7-10], 43[41-46], 8[7-], 29[27-32] mm for females. LV mass was significantly greater in males even after normalization for the body surface area (98[85-117] vs. 82[71-96] g/m2). Upper limits of BSA-indexed LV mass were 145 g/m2 for males and 124 g/m2 for females. The allometric exponent that described the LV mass-Height relationship were 2.5 in both sexes but 1.2 for males and 1.8 for females separately. E-wave velocity was 0.79 [0.65-0.90] cm/sec in males and 0.88 [0.78-0.99]cm/sec in females (p < 0.0001) but without significant gender differences in E/A ratio (limits: 0.75 and 2.1). The e'-wave velocity (lower limit = 8 cm/sec) decreased and E/e' ratio (Upper limit = 9) increased with aging. Upper limit of BSA-indexed left atrium volume was 38 mL/m2 for both sexes. In conclusion, normal values from a general population in West Africa differ from those established in Caucasian populations with greater LV mass and wall thicknesses.

Severe community-acquired pneumonia in Reunion Island: Epidemiological, clinical, and microbiological characteristics, 2016–2018

Purpose

No data are available on severe community-acquired pneumonia (CAP) in the French overseas department of Reunion Island. This is unfortunate as the microorganisms responsible for the disease are likely to differ from those in temperate regions due to a tropical climate and proximity to other islands of the Indian Ocean region. The aim of this study was to assess the epidemiological, clinical, prognosis, and microbiological characteristics of patients with severe CAP in Reunion Island.

Materials and methods

This retrospective study evaluated all patients with CAP aged >18 years and hospitalized in one of the two intensive care units of Reunion Island between 2016 and 2018. Microorganisms were identified by culture from blood and respiratory samples, multiplex polymerase chain reaction from respiratory samples, urinary antigen tests, and serology.

Results

Over the study period, 573 cases of severe CAP were recorded, with a mean incidence of 22 per 100,000 person-years. The most frequently isolated microorganism was influenza (21.9%) followed by Streptococcus pneumoniae (12%). The influenza virus was detected in affected patients all year round. Twenty-four patients with severe CAP came from another island of the Indian Ocean region (4.2%), mainly Madagascar (>50%). Two of these patients presented with melioidosis and 4 were infected with Acinetobacter spp.

Conclusions

Our findings have major implications for the management of severe CAP in tropical regions. The most frequently isolated microorganism in patients with severe CAP in Reunion Island is influenza followed by S. pneumoniae. Physicians should be aware that influenza is the main cause of severe CAP in patients living in or returning from Reunion Island, where this virus circulates all year round.

Normal values of proximal aorta diameters in healthy Sub Saharan Africans: The TAHES study

OBJECTIVES

Reported ranges of normal values are mostly issued from studies performed with Caucasians. This study is a part of TAHES, a population-based prospective cohort study in Benin and aims to establish normal reference values for echocardiographic diameters of the proximal aorta in Africans.

METHODS

Transthoracic echocardiography (TTE) examinations were performed by four cardiologists following pre-defined protocols, and analyzed off-line by a single observer. Aortic root diameters were measured during diastole for sinuses of Vasalva (SV), sinotubular junction (STJ) and proximal ascending aorta (AA), and during systole for annulus. Upper limits were defined as the 95th percentiles.

RESULTS

We included 513 normotensive, non-diabetic, and cardiovascular disease-free individuals (206 men, 307 women, age 40 ± 14 years). The diameters of the proximal aorta were significantly greater in men. The inner-edge-to-inner-edge non-indexed upper values for the annulus, SV, STJ and AA were respectively 25, 34, 28.5, 32 mm in men and 22, 30, 26, 30 mm in women. The leading-edge-to-leading-edge upper values were respectively 38, 35, 36 for men and 34, 33, 32 mm for women. No significant differences between sexes were recorded for body surface area (BSA)-indexed diameters of the annulus, STJ and AA. BSA-indexed SV dimension was greater in men than women were. SV, STJ, AA indexed-diameters correlated with age in both sexes but not for annulus indexed-diameter.

CONCLUSION

Normal values from a general population in West Africa could to differ from those established in Caucasian populations. Ethnic-specific reference diameters are here proposed for appropriate diagnosis of proximal aortic diseases in sub-Saharan Africa.

Predicting factors for the need of extracorporeal membrane oxygenation for suicide attempts by cardiac medication: a single-center cohort study

BACKGROUND

Severe poisoning due to the overdosing of cardiac drugs can lead to cardiovascular failure. In order to decrease the mortality rate, the most severe patients should be transferred as quickly as possible to an extracorporeal membrane oxygenation (ECMO) center. However, the predictive factors showing the need for venous-arterial ECMO (VA-ECMO) had never been evaluated.

METHODS

A retrospective, descriptive, and single-center cohort study. All consecutive patients admitted in the largest ICU of Reunion Island (Indian Ocean) between January 2013 and September 2018 for beta-blockers (BB), calcium channel blockers (CCB), renin-angiotensin-aldosterone system blockers, digoxin or anti-arrythmic intentional poisonings were included. ECMO implementation was the primary outcome.

RESULTS

A total of 49 consecutive admissions were included. Ten patients had ECMO, 39 patients did not have ECMO. Three patients in ECMO group died, while no patients in the conventional group died. The most relevant ECMO-associated factors were pulse pressure and heart rate at first medical contact and pulse pressure, heart rate, arterial lactate concentration, liver enzymes and left ventricular ejection fraction (LVEF) at ICU-admission. Only pulse pressure at first medical contact and LVEF were significant after logistic regression.

CONCLUSION

A transfer to an ECMO center should be considered for a pulse pressure < 35 mmHg at first medical contact or LVEF < 20% on admission to ICU.

Titanate nanoribbon-based nanobiohybrid for potential applications in regenerative medicine

Nanoparticles capable of mimicking natural tissues represent a major technological advancement in regenerative medicine. In this pilot study, the development of a new nanohybrid composed of titanate nanoribbons to mimic the extracellular matrix is reported. During the first phase, nanoribbons were synthesized by hydrothermal treatment. Subsequently, titanate nanoribbons were functionalized by heterobifunctional polyethylene-glycol (PEG) to graft type I collagen on their surface. Biological properties of this new nanobiohybrid such as cytotoxicity to cardiac cells and platelet aggregation ability were evaluated. The so-formed nanobiohybrid permits cellular adhesion and proliferation favoring fine cardiac tissue healing and regeneration.

Titanate nanoribbons functionalized by heterobifunctional polymer and type I collagen for cellular adhesion and proliferation. This new nanobiohybrid affected neither cytotoxicity nor platelet aggregation ability.

Normal values of aortic root diameters in sub saharan africans: the TAHES study

Introduction

Reference values of aortic root diameters (ARD) are proposed to define normal versus diseased aorta. However, reported ranges of normal values are mostly issued from Caucasian cohorts. Data on blacks African subjects are sparse and not issued from community-dwelling cohorts.

Purpose

Our study aimed to establish reference values for ARD in a Beninese general population cohort.

Methods

This study is a part of TAHES, a population-based prospective cohort study initiated in 2015 in the district of Tanvè, Republic of Benin. Demographic, blood pressure and blood glucose data were collected using a questionnaire adapted from WHO-STEPS tools. Transthoracic echocardiography examinations were performed by 4 cardiologists, and analyzed off-line by a single observer. ARD were measured using inner-edge to inner-edge diameters during diastole for sinuses of Vasalva (SV), sinotubular junction (STJ) and proximal ascending aorta (AA), and during systole for annulus. Normal limits were defined as the 95th percentiles. Variables are presented as mean ±SD (5th-95th percentiles).

Results

We included 513 normotensive, non-diabetic and cardiovascular disease-free individuals (206 men and 307 women, age 40±14 years [26–68]). The absolute values of ARD were significantly greater in men: the non-indexed ARD values for the annulus, SV, STJ and AA were respectively 21.3±2 (18.5–25), 28.5±3.4 (23–34), 24.1±3 (19–29) and 27±3 (22.5–32) mm for men and 19.3±1.8 (1.8 (15- 22), 25.8±2.8 (21.6–30), 22±2.7 (18–26) and 24.8±2.8 (21–30) mm for women, respectively (all p&lt;0.0001). No significant differences between sexes were recorded for body surface area (BSA)-indexed ARD for Annulus, STJ and AA. BSA-indexed SV dimension was greater in men (17.3±2.6 mm; 13.5–22) than women (16.8±2.5 mm; 13–21). There was a correlation between SV, STJ, AA indexed-diameters and age in both sexes but not for annulus indexed-diameter (r=0.14, 0.19 and 0.36 for women and 0.34, 0.45 and 0.32 for men, all p&lt;0.05). The upper limits for ARD are summarized in Table 1. In order to compare these values to those in Caucasians, the data of the NORRE study are also displayed.

Conclusion

Normal values from a general population in West Africa appear could to differ from those established in Caucasian populations. This ethnic-appropriate reference is proposed for appropriate diagnosis in patients in sub-Saharan Africa.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): APREL (CHU Limoges) Table 1

Necrotizing Skin and Soft Tissue Infections Admitted to Intensive Care Unit in Reunion Island: A Retrospective Cohort Study

This retrospective and single-center study in Reunion Island (Indian Ocean) assessed frequency, mortality, causative pathogens of severe necrotizing skin, and necrotizing skin and soft tissue infections (NSSTIs) admitted in intensive care unit (ICU). Sixty-seven consecutive patients were included from January 2012 to December 2018. Necrotizing skin and soft tissue infection represented 1.06% of total ICU admissions. We estimate the incidence of NSSTI requiring ICU at 1.21/100,000 person/years in Reunion Island. Twenty (30%) patients were receiving nonsteroidal anti-inflammatory drugs (NSAIDs) prior to admission in ICU and 40 (60%) were diagnosed patients with diabetes. Sites of infection were the lower limb in 52 (78%) patients, upper limb in 4 (6%), and perineum in 10 (15%). The surgical treatment was debridement for 40 patients, whereas 11 patients required an amputation. The most commonly isolated microorganisms were Streptococci (42%) and Gram-negative bacteria (22%).The mortality rate was 25.4%. NSAIDs did not influence mortality when interrupted upon admission to ICU.

Impact of levosimendan on weaning from peripheral venoarterial extracorporeal membrane oxygenation in intensive care unit

BACKGROUND

Few data are available on the impact of levosimendan in refractory cardiogenic shock patients undergoing peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO). The aim of this study was to evaluate the impact of levosimendan on VA-ECMO weaning in patients hospitalized in intensive care unit (ICU).

METHODS

This retrospective cohort study was conducted in a French university hospital from 2010 to 2017. All patients hospitalized in ICU undergoing VA-ECMO were consecutively evaluated.

RESULTS

A total of 150 patients undergoing VA-ECMO were eligible for the study. Thirty-eight propensity-matched patients were evaluated in the levosimendan group and 65 in the non-levosimendan group. In patients treated with levosimendan, left ventricular ejection fraction had increased from 21.5 ± 9.1% to 30.7 ± 13.5% (P < 0.0001) and aortic velocity-time integral from 8.9 ± 4 cm to 12.5 ± 3.8 cm (P = 0.002) 24 h after drug infusion. After propensity score matching, levosimendan was the only factor associated with a significant reduction in VA-ECMO weaning failure rates (hazard ratio = 0.16; 95% confidence interval 0.04-0.7; P = 0.01). Kaplan-Meier survival curves showed that survival rates at 30 days were 78.4% for the levosimendan group and 49.5% for the non-levosimendan group (P = 0.02). After propensity score matching analysis, the difference in 30-day mortality between the two groups was not significant (hazard ratio = 0.55; 95% confidence interval 0.27-1.10; P = 0.09).

CONCLUSIONS

Our results suggest that levosimendan was associated with a beneficial effect on VA-ECMO weaning in ICU patients.

The monocytosis during human leptospirosis is associated with modest immune cell activation states

Leptospirosis is a life-threatening zoonotic disease and it has been hypothesized that the innate immune system fails to control the infection through ill-characterized mechanisms. The aim of this observational study was to better evaluate the activation processes of monocytes at the early stage of the disease. Blood samples were taken from healthy donors (n = 37) and patients hospitalized for either non-severe (n = 25) or severe (n = 32) leptospirosis. Monocyte cell counts and phenotypes were assessed by flow cytometry. We analysed the expression of several cell activation markers: CD14, CD16, HLA-DR, CD69, TLR2, TLR4, CD11b and CD11c. Although monocyte values at admittance were not significantly different from controls, patients experienced significant monocytosis at 1.33 × 10⁹/L (p < 0.0001 compared to controls: 0.56 × 10⁹/L) during their hospital stay. This monocytosis observed during hospital stay was correlated to several surrogate markers of organ injury. Non-classical (CD14-CD16+) and intermediate (CD14+CD16+) monocyte subsets increased compared to controls (p < 0.05). Accordingly, classical monocyte subset (CD14+CD16-) showed decreased percentages (p < 0.0001). Levels of several cell surface activation molecules were decreased: HLA-DR involved in MHC class II antigen presentation, integrins CD11b and CD11c implicated in phagocytosis and cell recruitment (p < 0.0001). None of these parameters had a prognostic value. Results from this study showed that during acute human leptospirosis, patients experienced monocytosis with a switch toward an inflammation-related phenotype contrasted by low expression levels of markers implicated in monocyte function.

Intensive care admission for Coronavirus OC43 respiratory tract infections

Background

Coronavirus OC43 infection causes severe pneumonia in patients presenting with comorbidities, but clinical signs alone do not allow for viral identification.

Objectives

To analyze acute manifestations of Coronavirus OC43 infections and outcomes of patients admitted to an intensive care unit (ICU).

Patients and methods

Retrospective and monocentric study performed during a Coronavirus OC43 outbreak. We used multiplex PCR to detect an OC43 outbreak in Reunion Island during the 2016 Southern Hemisphere's winter: seven admissions to the ICU.

Results

Mean age of patients was 71 [67;76] years, SAPS II was 42 [28;53], pneumonia severity index 159 [139;182] vs 73 [40.5;107] for patients in medical wards, and 43% required mechanical ventilation. Comorbidities were diabetes mellitus (87%), chronic respiratory failure (57%), and chronic renal failure (29%). One patient died from Haemophilus influenzae co-infection.

Conclusion

As for MERS Co-V infections, underlying comorbidities impacted the clinical outcomes of OC43 infections.

Complication patterns in patients undergoing venoarterial extracorporeal membrane oxygenation in intensive care unit: Multiple correspondence analysis and hierarchical ascendant classification

Background

Treatment by venoarterial extracorporeal membrane oxygenation (VA-ECMO) is widely used today, even though it is associated with high risks of complications and death. While studies have focused on the relationship between some of these complications and the risk of death, the relationship between different complications has never been specifically examined, despite the fact that the occurrence of one complication is known to favor the occurrence of others. Our objective was to describe the relationship between complications in patients undergoing VA-ECMO in intensive care unit (ICU) and to identify, if possible, patterns of patients according to complications.

Methods and findings

As part of a retrospective cohort study, we conducted a multiple correspondence analysis followed by a hierarchical ascendant classification in order to identify patterns of patients according to main complications (sepsis, thromboembolic event, major transfusion, major bleeding, renal replacement therapy) and in-ICU death. Our cohort of 145 patients presented an in-ICU mortality rate of 50.3%. Morbidity was high, with 36.5% of patients presenting three or more of the five complications studied. Multiple correspondence analysis revealed a cumulative inertia of 76.9% for the first three dimensions. Complications were clustered together and clustered close to death, prompting the identification of four patterns of patients according to complications, including one with no complications.

Conclusions

Our study, based on a large cohort of patients undergoing VA-ECMO in ICU and presenting a mortality rate comparable to that reported in the literature, identified numerous and often interrelated complications. Multiple correspondence analysis and hierarchical ascendant classification yielded clusters of patients and highlighted specific links between some of the complications studied. Further research should be conducted in this area.

[Is it worth delivering Direct-Current Counter shock to critically ill patients with supra-ventricular tachyarrhythmia?]

Supra-ventricular tachyarrhythmia and its treatment have been poorly investigated in ICU patients.

AIMS

To evaluate efficacy and safety of cardioversion for supra-ventricular tachyarrhythmia in the intensive care unit (ICU).

PATIENTS AND METHODS

Prospective inclusion of all patients who presented supra-ventricular tachyarrhythmias lasting≥30seconds in a single medico-surgical ICU, except cardiac surgery. Anti-arrhythmic drugs and/or direct-current cardioversion were administered on a liberal basis.

RESULTS

During the 15-month study period, 108/846 patients (12.8%) experienced supra-ventricular tachyarrhythmias. Anti-arrhythmic drugs were administered in 78 patients (72%); mostly amiodarone (92%), and/or magnesium (23%), resulting in an overall conversion rate of 68%. Direct-current cardioversion was used in 26 patients (24%), (24 patients received drug enhancement by anti-arrhythmic drugs) with an immediate 80.8%-success rate.

CONCLUSION

Direct-current cardioversion was associated with sustained conversion to sinus rhythm in 80.8% of ICU patients with supra-ventricular tachyarrhythmias, although most of them had already received drug enhancement.

Determinants and prognosis of high-sensitivity cardiac troponin T peak plasma concentration in patients hospitalized for non-cardiogenic shock

Purpose:

The aim of this study was to assess the determinants and prognostic value of high-sensitivity cardiac troponin T peak plasma concentration in intensive care unit patients with non-cardiogenic shock.

Material and methods:

A prospective observational cohort study was conducted in a single intensive care unit between November 2014 and December 2015.

Results:

During the study period, 206 patients were hospitalized in the intensive care unit for non-cardiogenic shock and the median peak high-sensitivity cardiac troponin T was 55.1 [24.5–136] pg/mL. A multivariate analysis combining all variables showed that higher body mass index (t = 2.52, P = 0.01), lower left ventricular systolic function (t = −2.73, P = 0.007), higher white blood cell count (t = 3.72, P = 0.0001), lower creatinine clearance (t = −2.84, P = 0.0005), higher lactate level (t = 2.62, P = 0.01) and ST-segment depression (t = 3.98, P = 0.0001) best correlated with log₁₀-transformed high-sensitivity cardiac troponin T peak plasma concentration. After multivariate analysis, the high-sensitivity cardiac troponin T peak was not associated with a significant reduction of in-hospital mortality (adjusted odds ratio = 0.99 (95% confidence interval: 0.93–1.02)).

Conclusion:

High-sensitivity cardiac troponin T elevation was very common in patients hospitalized for non-cardiogenic shock. The factors significantly associated with high-sensitivity cardiac troponin T peak plasma concentration were higher body mass index, decreased left ventricular systolic ejection fraction, higher leucocyte count, decreased renal function, increased lactate level, and ST-segment depression. The high-sensitivity cardiac troponin T peak was not significantly associated with in-hospital mortality in this setting.

Radiolabeled F(ab')2-cetuximab for theranostic purposes in colorectal and skin tumor-bearing mice models

PURPOSE

This study aimed to investigate theranostic strategies in colorectal and skin cancer based on fragments of cetuximab, an anti-EGFR mAb, labeled with radionuclide with imaging and therapeutic properties, ¹¹¹In and ¹⁷⁷Lu, respectively.

METHODS

We designed F(ab')₂-fragments of cetuximab radiolabeled with ¹¹¹In and ¹⁷⁷Lu. ¹¹¹In-F(ab')₂-cetuximab tumor targeting and biodistribution were evaluated by SPECT in BalbC nude mice bearing primary colorectal tumors. The efficacy of ¹¹¹In-F(ab')₂-cetuximab to assess therapy efficacy was performed on BalbC nude mice bearing colorectal tumors receiving 17-DMAG, an HSP90 inhibitor. Therapeutic efficacy of the radioimmunotherapy based on ¹⁷⁷Lu-F(ab')₂-cetuximab was evaluated in SWISS nude mice bearing A431 tumors.

RESULTS

Radiolabeling procedure did not change F(ab')₂-cetuximab and cetuximab immunoreactivity nor affinity for HER1 in vitro. ¹¹¹In-DOTAGA-F(ab')₂-cetuximab exhibited a peak tumor uptake at 24 h post-injection and showed a high tumor specificity determined by a significant decrease in tumor uptake after the addition of an excess of unlabeled-DOTAGA-F(ab')₂-cetuximab. SPECT imaging of ¹¹¹In-DOTAGA-F(ab')₂-cetuximab allowed an accurate evaluation of tumor growth and successfully predicted the decrease in tumor growth induced by 17-DMAG. Finally, ¹⁷⁷Lu-DOTAGA-F(ab')₂-cetuximab radioimmunotherapy showed a significant reduction of tumor growth at 4 and 8 MBq doses.

CONCLUSIONS

¹¹¹In-DOTAGA-F(ab')₂-cetuximab is a reliable and stable tool for specific in vivo tumor targeting and is suitable for therapy efficacy assessment. ¹⁷⁷Lu-DOTAGA-F(ab')₂-cetuximab is an interesting theranostic tool allowing therapy and imaging.

Case Report: Severe Imported Influenza Infections Developed during Travel in Reunion Island

We report two cases of severe influenza infection imported by tourist patients from their country of origin and developed during travel. While studies have reported cases of influenza infections acquired during travel, here we examine two cases of severe influenza infection contracted in the country of origin that led to diagnosis and therapeutic problems in the destination country. No international recommendation exists concerning influenza vaccination before travel, and few countries recommend it for all travelers. Our study suggests that travel should be canceled when infectious signs are observed before departure. Influenza is a very common infection that is often benign, but sometimes very severe. The most severe cases include shock, acute respiratory distress syndrome (ARDS), myocarditis, rhabdomyolysis, and multiple organ failure. Management can require exceptional therapies, such as extracorporeal membrane oxygenation. A number of studies have focused on influenza infection in travelers. Cases of influenza acquired during travel have been reported in this literature, but no study has examined cases of influenza imported from the country of origin and developed while abroad. The latter situation may lead to 1) diagnostic problems during the nonepidemic season or in places where diagnostic techniques are lacking and 2) therapeutic difficulties resulting from the unavailability of techniques for the management of severe influenza infection in tourist areas. Here, we report two cases of extremely severe influenza infection imported by tourists from their country of origin and developed during travel.

Hemodynamic Assessment of Patients With Septic Shock Using Transpulmonary Thermodilution and Critical Care Echocardiography: A Comparative Study

BACKGROUND

To assess the agreement between transpulmonary thermodilution (TPT) and critical care echocardiography (CCE) in ventilated patients with septic shock.

METHODS

Ventilated patients in sinus rhythm requiring advanced hemodynamic assessment for septic shock were included in this prospective multicenter descriptive study. Patients were assessed successively using TPT and CCE in random order. Data were interpreted independently at bedside by two investigators who proposed therapeutic changes on the basis of predefined algorithms. TPT and CCE hemodynamic assessments were reviewed offline by two independent experts who identified potential sources of discrepant results by consensus. Lactate clearance and outcome were studied.

RESULTS

A total of 137 patients were studied (71 men; age, 61 ± 15 years; Simplified Acute Physiologic Score, 58 ± 18; Sequential Organ Failure Assessment, 10 ± 3). TPT and CCE interpretations at bedside were concordant in 87/132 patients (66%) without acute cor pulmonale (ACP), resulting in a moderate agreement (kappa, 0.48; 95% CI, 0.37-0.60). Experts' adjudications were concordant in 100/129 patients without ACP (77.5%), resulting in a good intertechnique agreement (kappa, 0.66; 95% CI, 0.55-0.77). In addition to ACP (n = 8), CCE depicted a potential source of TPT inaccuracy in 8/29 patients (28%). Lactate clearance at H6 was similar irrespective of the concordance of online interpretations of TPT and CCE (55/84 [65%] vs 32/45 [71%], P = .55). ICU and day 28 mortality rates were similar between patients with concordant and discordant interpretations (29/87 [36%] vs 13/45 [29%], P = .60; and 31/87 [36%] vs 16/45 [36%], P = .99, respectively).

CONCLUSIONS

Agreement between TPT and CCE was moderate when interpreted at bedside and good when adjudicated offline by experts, but without impact on lactate clearance and mortality.

Pattern and consequences of cardiologic medications management for patients with elevated troponin I upon admission into an intensive care unit not linked to type 1 acute myocardial infarction: A prospective observational cohort study

OBJECTIVES

No recommendations are currently available to help the clinician with the pharmacological management of intensive care unit (ICU) patients with elevated cardiac troponin (cTn) not linked to type 1 AMI. The aim of this study was to evaluate the pattern of cardiologic medications for patients with elevated cTnI in ICU not link to type 1 AMI and their effects on in-hospital mortality.

MATERIAL AND METHODS

A prospective observational cohort study conducted in two ICU units. Patients with increased plasma concentration of cTnI at admission not linked to type 1 AMI were consecutively included.

RESULTS

One hundred and ninety of the 835 patients admitted (23%) had an increased plasma concentration of cTnI not related to type 1 AMI. Antiplatelet therapy (AT) and statin were prescribed in 56 (29.5%) and 50 (26.3%) of patients, respectively. Others cardiologic medications were prescribed in less than 5% of all cases and were considered as contraindicated in more than 50% of cases. Antiplatelet therapy was the only cardiologic treatment associated with reduction of in-hospital mortality following uni- and multivariate analysis. The death rate was 23% and 40% in these patients treated with and without AT, respectively (aOR=0.39 [95% CI: 0.15-0.97]).

CONCLUSIONS

Statin and AT were frequently prescribed to patients with a cTnI elevation not linked to type 1 AMI. This study suggests that AT in patients with an increased plasma concentration of cTnI, not related to type 1 AMI in ICU, could reduce in-hospital mortality.

Réunion Island prepared for possible Zika virus emergence, 2016

Zika virus (ZIKV) has recently spread widely and turned into a major international public health threat. Réunion appears to offer conditions particularly favourable to its emergence and therefore prepared to face possible introduction of the virus. We designed a scaled surveillance and response system with specific objectives, methods and measures for various epidemiological phases including a potential epidemic. Several tools were developed in order to (i) detect individual cases (including a large information campaign on the disease and suspicion criteria), (ii) monitor an outbreak through several complementary systems allowing to monitor trends in disease occurrence and geographic spread and (iii) detect severe forms of the disease in collaboration with hospital clinicians. We put the emphasis on detecting the first cases in order to contain the spread of the virus as much as possible and try to avoid progress towards an epidemic. Our two main strengths are a powerful vector control team, and a close collaboration between clinicians, virologists, epidemiologists, entomologists and public health authorities. Our planned surveillance system could be relevant to Europe and island settings threatened by Zika virus all over the world.

A major impact of the influenza seasonal epidemic on intensive care units, Réunion, April to August 2016

The 2016 seasonal influenza in Réunion in the southern hemisphere, was dominated by influenza A(H1N1)pdm09 (possibly genogroup 6B.1). An estimated 100,500 patients with acute respiratory infection (ARI) consulted a physician (cumulative attack rate 11.9%). Sixty-six laboratory-confirmed cases (65.7/100,000 ARI consultations) were hospitalised in an intensive care unit, the highest number since 2009. Impact on intensive care units was major. Correlation between severe cases was 0.83 between Réunion and France and good for 2009 to 2015.

Major Neutrophilia Observed in Acute Phase of Human Leptospirosis Is Not Associated with Increased Expression of Granulocyte Cell Activation Markers

It has long been known that pathogenic Leptospira can mobilize the immune system but the specific contribution of neutrophils to control the infectious challenge remains to be clarified. We herein analyzed the phenotype of circulating neutrophils of patients with leptospirosis and healthy controls for the expression of toll-like receptor (TLR) type 2 (TLR2, to sense the leptospiral LPS) and several activation markers: interleukin 8 chemokine receptor CD182 (CXCR2), CD11b of the integrin/opsonin complement receptor type 3 (CR3) and CD15 (ligand of the selectin). The plasmatic level of the main CD182 ligand, interleukin 8 (CXCL8), was measured by ELISA. Hospitalized leptospirosis cases showed marked neutrophilia, particularly in the most severe cases. Interestingly, TLR2 was significantly increased in leptospirosis but identical levels of CD182 and CD11b were detected when compared to controls. CD15 was significantly decreased on neutrophils in leptospirosis but returned to normal within 1 month. Basal levels of IL-8 were measured in control subjects and were not increased in leptospirosis cases at the initial stage of the disease. In conclusion, we observed that neutrophils failed to regulate the expression of several of the receptors involved in cell activation and recruitment. This study further emphasizes the paradigm that neutrophils may be impaired in their overall capacity to thwart bacterial infection in leptospirosis patients.

[Post nearly Drowning Vibrio alginolyticus Septicemia Acquired in Reunion (Indian Ocean)]

AbstractWe report the first case of Vibrio alginolyticus septicemia in the Indian Ocean (Reunion Island), in a patient (70-year-old-man) with multiple underlying conditions, following a nearly drowning in the lagoon of Reunion. From now on, V. alginolyticus should be considered as a possible agent of septicemia in the Indian Ocean, particularly following marine activities.

Assessment of the National French recommendations regarding the dosing regimen of 8mg/kg of gentamicin in patients hospitalised in intensive care units

INTRODUCTION

To assess the French National Agency for Medicines and Health Products Safety (ANSM) guidelines concerning the peak plasma concentration (Cmax) of gentamicin when using a loading dose of 8mg/kg administered in patients hospitalised in the intensive care unit (ICU).

PATIENTS AND METHODS

A prospective observational cohort study conducted in one ICU.

RESULTS

During the study period, 34 patients with a median simplified acute physiology score 2 of 54 [44-70] received a median dose of 8 [7.9-8.1] mg/kg of gentamicin. The median Cmax was 17.5 [15.4-20.7] mg/L and no patient had a Cmax>30mg/L. Twenty-four of 34 patients (71%) had a Cmax>16mg/L. Following multivariate analysis, the only factor associated with Cmax<16mg/L was a positive fluid balance 24hours before gentamicin administration (per 1000mL increment) (OR: 0.37, 95% CI: 0.18-0.77, P=0.008).

CONCLUSIONS

These results suggest that a Cmax>30mg/L [which corresponds to approximately 8 times the minimal inhibiting concentrations (MIC) breakpoints for Pseudomonas aeruginosa and Enterobacteriaceae with intermediate sensitivity] of gentamicin as recommended by ANSM guidelines seems impossible to obtain with a loading dose of 8mg/kg in the ICU. A loading dose of 8mg/kg should probably not be used in the empiric antibiotic treatment of infection due to non-fermenting Gram-negative bacilli and Enterobacteriaceae with intermediate sensitivity whose MIC breakpoint is 4mg/L. A Cmax>16mg/L was not reached in almost 30% of patients, particularly in the group with a positive fluid balance who require higher doses than currently recommended.

Influence of Surface Charge and Polymer Coating on Internalization and Biodistribution of Polyethylene Glycol-Modified Iron Oxide Nanoparticles

The aim of this study was to investigate the influence of the surface charge and coating of Superparamagnetic Iron Oxide Nanoparticles (SPIONs) on their in vitro and in vivo behaviors. Neutral and negatively-charged PEG-based SPIONs were synthesized and compared to Resovist, a carboxydextran-based SPION currently used in clinics. Their cytotoxicity, cell internalization, and potential as contrast agents for magnetic resonance imaging were assessed. Neutral pegylated SPIONs were internalized less readily by the reticuloendothelial system and showed a lower uptake by the liver, compared to negatively-charged SPIONs (with carboxydextran and PEG). These results suggested that the charge of functionalized SPIONs was more relevant for their biological interactions than the nature of their coating.

Right over left ventricular end-diastolic area relevance to predict hemodynamic intolerance of high-frequency oscillatory ventilation in patients with severe ARDS

Background

High-frequency oscillatory ventilation (HFOV) does not improve the prognosis of ARDS patients despite an improvement in oxygenation. This paradox may partly be explained by HFOV hemodynamic side-effects on right ventricular function. Our goal was to study the link between HFOV and hemodynamic effects and to test if the pre-HFOV right over left ventricular end-diastolic area (RVEDA/LVEDA) ratio, as a simple parameter of afterload-related RV dysfunction, could be used to predict HFOV hemodynamic intolerance in patients with severe ARDS.

Methods

Twenty-four patients were studied just before and within 3 h of HFOV using transthoracic echocardiography and transpulmonary thermodilution.

Results

Before HFOV, the mean PaO₂/FiO₂ ratio was 89 ± 23. The number of patients with a RVEDA/LVEDA ratio >0.6 significantly increased after HFOV [11 (46 %) vs. 17 (71 %)]. Although HFOV did not significantly decrease the arterial pressure (systolic, diastolic, mean and pulse pressure), it significantly decreased the cardiac index (CI) by 13 ± 18 % and significantly increased the RVEDA/LVEDA ratio by 14 ± 11 %. A significant correlation was observed between pre-HFOV RVEDA/LVEDA ratio and CI diminution after HFOV (r = 0.78; p < 0.0001). A RVEDA/LVEDA ratio superior to 0.6 resulted in a CI decrease >15 % during HFOV with a sensitivity of 80 % (95 % confidence interval 44–98 %) and a specificity of 79 % (confidence interval 49–95 %).

Conclusion

The RVEDA/LVEDA ratio measured just before HFOV predicts the hemodynamic intolerance of this technique in patients with severe ARDS. A high ratio under CMV raises questions about the use of HFOV in such patients.

Trial registration: ClinicalTrials.gov: NCT01167621

Risk Factors for Colonization With Multidrug-Resistant Bacteria Among Patients Admitted to the Intensive Care Unit After Returning From Abroad

BACKGROUND

Few national recommendations exist on management of patients returning from abroad and all focus on hospitalized patients. Our purpose was to compare, in an intensive care unit (ICU), the admission prevalence and acquisition of multidrug-resistant (MDR) bacteria carriage in patients with ("Abroad") or without ("Local") a recent stay abroad, and then identify the risk factors in "Abroad" patients.

METHODS

In this retrospective study, we reviewed charts of all the patients hospitalized in the ICU unit from January 2011 through July 2013 with hygiene samplings performed. We identified all patients who had stayed abroad ("Abroad") within 6 months prior to ICU admission.

RESULTS

Of 1,842 ICU patients, 129 (7%) "Abroad" patients were reported. In the "Abroad" group, the rate of MDR strain carriage was higher at admission (33% vs 6.7%, p < 0.001) and also more often diagnosed during the ICU stay (acquisition rate: 17% vs 5.2%, p < 0.001) than in "Local" patients. Risk factors associated with MDR bacteria carriage at admission in "Abroad" patients were diabetes mellitus [odds ratio (OR) 5.1 (1.7-14.8), p = 0.003] and "hospitalization abroad with antibiotic treatment" [OR 10.7 (4.2-27.3), p < 0.001]. Hospitalization abroad without antibiotic treatment was not identified as a risk factor.

CONCLUSIONS

The main factor associated with MDR bacteria carriage after a stay abroad seems to be a hospitalization abroad only in case of antibiotic treatment abroad. Screening and isolation of "Abroad" patients should be recommended, even in case of a first negative screening.

Delayed diagnosis of high drug-resistant microorganisms carriage in repatriated patients: three cases in a French intensive care unit

We report three cases of high drug-resistant microorganisms (HDRMO) carriage by patients repatriated from a foreign country. National recommendations suggest systematic screening and contact isolation pending results of admission screening of all patients recently hospitalized abroad. HDRMO carriage (carbapenem-resistant Acinetobacter baumanii and carbapenemase-producing Enterobacteriaceae) was not isolated on admission screening swabs, but later between 3 and 8 days after admission. In absence of cross-transmission, two hypotheses seem possible: a false-negative test on admission, or a late onset favored by antibiotic pressure. Prolonged isolation may be discussed even in case of negative screening on admission from high-risk patients.

A multi-step mechanism and integrity of titanate nanoribbons

Using TEM and EFTEM, we showed that titanate nanoribbons are made of an assembly of smaller ribbons juxtaposed and piled up on one another. We also studied their morphological, structural and chemical characteristics using XRD, Raman and XPS. New insights were obtained regarding their forming mechanism and structural integrity.

Influenza season in Réunion dominated by influenza B virus circulation associated with numerous cases of severe disease, France, 2014

The 2014 seasonal influenza in Réunion, a French overseas territory in the southern hemisphere, was dominated by influenza B. Resulting morbidity impacted public health. Relative to the total number of all-cause consultations over the whole season, the rate of acute respiratory infection (ARI) consultations was 6.5%. Severe disease occurred in 32 laboratory-confirmed influenza cases (31.7 per 100,000 ARI consultations), 16 with influenza B. The observed disease dynamics could present a potential scenario for the next European influenza season.

Stress (Tako-tsubo) cardiomyopathy in critically-ill patients

BACKGROUND

Stress cardiomyopathy (SC) is a transient ventricular dysfunction rarely described in the critical care setting.

OBJECTIVE

To evaluate the mechanisms, incidence, treatment and prognosis of SC.

METHOD

This is a retrospective observational study of every critically-ill patient admitted to the ICU over a period of two years.

RESULTS

Among 1314 patients admitted in the ICU, 20 patients (1.5%) were diagnosed with SC. A total of 249 patients experienced cardiogenic shock, whereas 8% were suffering from SC. SC was suspected because of hemodynamic impairment (80% of cases), ECG modifications (15%) and/or dyspnea (15%). SC was apical (typical Tako-tsubo) in 90% and atypical in 10% of cases. Several mechanisms or conditions may explain the occurrence of SC and are may be combined: catecholamine toxicity (45%), psychological stress, seizures or neurological impairment (35%), non-epicardial coronary ischemia (20%) and left ventricular outflow track (LVOT) obstruction (10%). SC could have indirectly caused death by worsening heart failure in three patients and arrhythmias were seen in 40% of patients. SAPS2, renal impairment, malnutrition, norepinephrine infusion and thrombocytopenia were associated with death in the univariate analysis. Catecholamines were required in 85% and intra-aortic balloon pump in 20% of patients.

CONCLUSIONS

SC is a rare reversible cardiac impairment in the critically-ill patient that can induce arrhythmias and cardiogenic shock. The likely mechanisms are combined: catecholamine toxicity, stress or neurological involvement and less frequently ischemia or LVOT obstruction.

[Severe cases of Salmonella non typhi infections on sickle cell patients in Réunion Island]

We report two cases of septic shocks due to Salmonella non typhi infection on sickle cell patients admitted to an intensive care unit. Such patients should enforce food hygiene measures, especially under tropical settings, to avoid potentially deadly severe infections.

Performance of two new automated assays for measuring von Willebrand activity: HemosIL AcuStar and Innovance

The ristocetin cofactor activity assay (VWF:RCo) is the reference method for assessing von Willebrand factor (VWF) activity but remains difficult to perform, and the coefficient of variation of the method is high (about 20-30%). This study evaluated and compared the performance for measuring the VWF activity of two newly commercialised assays [VWF:Ac Innovance (VWF:Ac) and VWF:RCo Acustar (VWF:RCo Acu)] with the reference VWF:RCo aggregation in 123 pathological plasma samples. The correlation and concordance between both new tests (VWF:RCo-Acu and VWF:Ac) and the reference VWF:RCo were good. The results of the VWF activity to VWF antigen ratio were also comparable whatever the method for the classification of VWF deficiency in all patients. Our results showed that both new tests could replace the "gold standard" VWF:RCo in aggregometry with several benefits: they are fully automated, easier and faster to perform, better adapted to emergency situations if necessary.