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Gómez H, Zarbock A, Pastores SM, Frendl G, Bercker S, Asfar P, Conrad SA, Creteur J, Miner J, Mira JP, Motsch J, Quenot JP, Rimmelé T, Rosenberger P, Vinsonneau C, Birch B, Heskia F, Textoris J, Molinari L, Guzzi LM, Ronco C, Kellum JA. Feasibility Assessment of a Biomarker-Guided Kidney-Sparing Sepsis Bundle: The Limiting Acute Kidney Injury Progression In Sepsis Trial. Crit Care Explor 2023; 5:e0961. [PMID: 37614799 PMCID: PMC10443738 DOI: 10.1097/cce.0000000000000961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023] Open
Abstract
OBJECTIVES To determine the feasibility, safety, and efficacy of a biomarker-guided implementation of a kidney-sparing sepsis bundle (KSSB) of care in comparison with standard of care (SOC) on clinical outcomes in patients with sepsis. DESIGN Adaptive, multicenter, randomized clinical trial. SETTING Five University Hospitals in Europe and North America. PATIENTS Adult patients, admitted to the ICU with an indwelling urinary catheter and diagnosis of sepsis or septic shock, without acute kidney injury (acute kidney injury) stage 2 or 3 or chronic kidney disease. INTERVENTIONS A three-level KSSB based on Kidney Disease: Improving Global Outcomes (KDIGOs) recommendations guided by serial measurements of urinary tissue inhibitor of metalloproteinases-2 and insulin-like growth factor-binding protein 7 used as a combined biomarker [TIMP2]•[IGFBP7]. MEASUREMENTS AND MAIN RESULTS The trial was stopped for low enrollment related to the COVID-19 pandemic. Nineteen patients enrolled in five sites over 12 months were randomized to the SOC (n = 8, 42.0%) or intervention (n = 11, 58.0%). The primary outcome was feasibility, and key secondary outcomes were safety and efficacy. Adherence to protocol in patients assigned to the first two levels of KSSB was 15 of 19 (81.8%) and 19 of 19 (100%) but was 1 of 4 (25%) for level 3 KSSB. Serious adverse events were more frequent in the intervention arm (4/11, 36.4%) than in the control arm (1/8, 12.5%), but none were related to study interventions. The secondary efficacy outcome was a composite of death, dialysis, or progression of greater than or equal to 2 stages of acute kidney injury within 72 hours after enrollment and was reached by 3 of 8 (37.5%) patients in the control arm, and 0 of 11 (0%) patients in the intervention arm. In the control arm, two patients experienced progression of acute kidney injury, and one patient died. CONCLUSIONS Although the COVID-19 pandemic impeded recruitment, the actual implementation of a therapeutic strategy that deploys a KDIGO-based KSSB of care guided by risk stratification using urinary [TIMP2]•[IGFBP7] seems feasible and appears to be safe in patients with sepsis.
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Affiliation(s)
- Hernando Gómez
- Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
- Outcomes Research Consortium, Cleveland, OH
| | - Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Critical Care Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gyorgy Frendl
- Department of Anesthesiology, Surgical ICU Translational Research Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sven Bercker
- Department of Anesthesia and Intensive Care Medicine, University Hospital of Leipzig, Leipzig, Germany
| | - Pierre Asfar
- Medical Intensive Care Department, University Hospital of Angers, Angers, France
| | - Steven A Conrad
- Departments of Medicine, Emergency Medicine and Pediatrics, Louisiana State University Health Sciences Center, Shreveport, LA
| | - Jaques Creteur
- Department of Intensive Care, Cliniques Universitaires de Bruxelles-Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgique
| | - James Miner
- Department of Emergency Medicine, Hennepin Health and University of Minnesota, Minneapolis, MN
| | - Jean Paul Mira
- Medical Intensive Care Unit, Cochin University Hospital, Groupe Hospitalier Paris Centre, AP-HP, Paris Cite University, Paris, France
| | - Johan Motsch
- Department of Anesthesiology, University Clinics Heidelberg, Heidelberg, Germany
| | - Jean-Pierre Quenot
- Department of Intensive Care, Burgundy University Hospital, Dijon, France
- Lipness Team, INSERM Research Center LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, Dijon, France
- INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Thomas Rimmelé
- Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Peter Rosenberger
- Department of Anesthesiology and Intensive Care Medicine, Tübingen University Hospital, Hoppe-Seyler-Straße, Tübingen, Germany
| | | | - Bob Birch
- US Data Sciences Department, US Data Sciences bioMerieux Inc, Hazelwood, MO
| | | | - Julien Textoris
- Global Medical Affairs, bioMérieux, Marcy l'Etoile, France
- Service d'Anesthésie et de Réanimation, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Luca Molinari
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Louis M Guzzi
- Cardiothoracic and Vascular Intensive Care Medicine, Orlando Regional Medical Center, Orlando, FL
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, University of Padova, Vicenza, Italy
| | - John A Kellum
- Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
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Vlaar APJ, Witzenrath M, van Paassen P, Heunks LMA, Mourvillier B, de Bruin S, Lim EHT, Brouwer MC, Tuinman PR, Saraiva JFK, Marx G, Lobo SM, Boldo R, Simon-Campos JA, Cornet AD, Grebenyuk A, Engelbrecht JM, Mukansi M, Jorens PG, Zerbib R, Rückinger S, Pilz K, Guo R, van de Beek D, Riedemann NC, Witzenrath M, van Paassen P, Heunks LM, Mourvillier B, de Bruin S, Lim EH, Brouwer MC, Tuinman PR, Saraiva JFK, Marx G, Lobo S, Boldo R, Simon-Campos J, Cornet AD, Grebenyuk A, Engelbrecht J, Mukansi M, Jorens PG, Zerbib R, Rückinger S, Pilz K, Guo R, van de Beek D, Riedemann NC, Bulpa P, Taccone FS, Hermans G, Diltoer M, Piagnerelli M, De Neve N, Freire AT, Pizzol FD, Marinho AK, Sato VH, Arns da Cunha C, Neuville M, Dellamonica J, Annane D, Roquilly A, Diehl JL, Schneider F, Mira JP, Lascarrou JB, Desmedt L, Dupuis C, Schwebel C, Thiéry G, Gründling M, Berger M, Welte T, Bauer M, Jaschinski U, Matschke K, Mercado-Longoria R, Gomez Quintana B, Zamudio-Lerma JA, Moreno Hoyos Abril J, Aleman Marquez A, Pickkers P, Otterspoor L, Hercilla Vásquez L, Seas Ramos CR, Peña Villalobos A, Gianella Malca G, Chávez V, Filimonov V, Kulabukhov V, Acharya P, Timmermans SA, Busch MH, van Baarle FL, Koning R, ter Horst L, Chekrouni N, van Soest TM, Slim MA, van Vught LA, van Amstel RB, Olie SE, van Zeggeren IE, van de Poll MC, Thielert C, Neukirchen D. Anti-C5a antibody (vilobelimab) therapy for critically ill, invasively mechanically ventilated patients with COVID-19 (PANAMO): a multicentre, double-blind, randomised, placebo-controlled, phase 3 trial. Lancet Respir Med 2022; 10:1137-1146. [PMID: 36087611 PMCID: PMC9451499 DOI: 10.1016/s2213-2600(22)00297-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/29/2022] [Accepted: 08/03/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Vilobelimab, an anti-C5a monoclonal antibody, was shown to be safe in a phase 2 trial of invasively mechanically ventilated patients with COVID-19. Here, we aimed to determine whether vilobelimab in addition to standard of care improves survival outcomes in this patient population. METHODS This randomised, double-blind, placebo-controlled, multicentre phase 3 trial was performed at 46 hospitals in the Netherlands, Germany, France, Belgium, Russia, Brazil, Peru, Mexico, and South Africa. Participants aged 18 years or older who were receiving invasive mechanical ventilation, but not more than 48 h after intubation at time of first infusion, had a PaO2/FiO2 ratio of 60-200 mm Hg, and a confirmed SARS-CoV-2 infection with any variant in the past 14 days were eligible for this study. Eligible patients were randomly assigned (1:1) to receive standard of care and vilobelimab at a dose of 800 mg intravenously for a maximum of six doses (days 1, 2, 4, 8, 15, and 22) or standard of care and a matching placebo using permuted block randomisation. Treatment was not continued after hospital discharge. Participants, caregivers, and assessors were masked to group assignment. The primary outcome was defined as all-cause mortality at 28 days in the full analysis set (defined as all randomly assigned participants regardless of whether a patient started treatment, excluding patients randomly assigned in error) and measured using Kaplan-Meier analysis. Safety analyses included all patients who had received at least one infusion of either vilobelimab or placebo. This study is registered with ClinicalTrials.gov, NCT04333420. FINDINGS From Oct 1, 2020, to Oct 4, 2021, we included 368 patients in the ITT analysis (full analysis set; 177 in the vilobelimab group and 191 in the placebo group). One patient in the vilobelimab group was excluded from the primary analysis due to random assignment in error without treatment. At least one dose of study treatment was given to 364 (99%) patients (safety analysis set). 54 patients (31%) of 177 in the vilobelimab group and 77 patients (40%) of 191 in the placebo group died in the first 28 days. The all-cause mortality rate at 28 days was 32% (95% CI 25-39) in the vilobelimab group and 42% (35-49) in the placebo group (hazard ratio 0·73, 95% CI 0·50-1·06; p=0·094). In the predefined analysis without site-stratification, vilobelimab significantly reduced all-cause mortality at 28 days (HR 0·67, 95% CI 0·48-0·96; p=0·027). The most common TEAEs were acute kidney injury (35 [20%] of 175 in the vilobelimab group vs 40 [21%] of 189 in the placebo), pneumonia (38 [22%] vs 26 [14%]), and septic shock (24 [14%] vs 31 [16%]). Serious treatment-emergent adverse events were reported in 103 (59%) of 175 patients in the vilobelimab group versus 120 (63%) of 189 in the placebo group. INTERPRETATION In addition to standard of care, vilobelimab improves survival of invasive mechanically ventilated patients with COVID-19 and leads to a significant decrease in mortality. Vilobelimab could be considered as an additional therapy for patients in this setting and further research is needed on the role of vilobelimab and C5a in other acute respiratory distress syndrome-causing viral infections. FUNDING InflaRx and the German Federal Government.
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Affiliation(s)
- Alexander P J Vlaar
- Department of Intensive Care, Amsterdam UMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, Netherlands,Prof Alexander P J Vlaar, Department of Intensive Care, University of Amsterdam, Amsterdam UMC, 1100DD Amsterdam, Netherlands
| | - Martin Witzenrath
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitätsmedizin Berlin, German Center for Lung Research, Berlin, Germany
| | | | - Leo M A Heunks
- Department of Intensive Care, Amsterdam UMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, Netherlands
| | - Bruno Mourvillier
- Medical Intensive Care Unit, University Hospital of Reims, Reims, France
| | - Sanne de Bruin
- Department of Intensive Care, Amsterdam UMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, Netherlands
| | - Endry H T Lim
- Department of Intensive Care, Amsterdam UMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, Netherlands
| | - Matthijs C Brouwer
- Department of Neurology, Amsterdam UMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care, Amsterdam UMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, Netherlands
| | | | - Gernot Marx
- Uniklinik RWTH Aachen, Klinik für Operative Intensivmedizin und Intermediate Care, Aachen, Germany
| | | | - Rodrigo Boldo
- Associação Educadora São Carlos, Hospital Mãe de Deus, Centro de Pesquisa, Porto Alegre, Brazil
| | | | | | | | | | - Murimisi Mukansi
- Helen Joseph Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | | | | | - Diederik van de Beek
- Department of Neurology, Amsterdam UMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, Netherlands
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Pajot O, Lakhal K, Lambert J, Gros A, Bruel C, Boulain T, Garot D, Das V, Timsit JF, Cerf C, Souweine B, Chaffaut C, Mentec H, Zahar JR, Mira JP, Jullien V. Empirical Antibiotic Therapy for Gram-Negative Bacilli Ventilator-Associated Pneumonia: Observational Study and Pharmacodynamic Assessment. Antibiotics (Basel) 2022; 11:antibiotics11111664. [PMID: 36421308 PMCID: PMC9686941 DOI: 10.3390/antibiotics11111664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/10/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Strong evidence suggests a correlation between pharmacodynamics (PD) index and antibiotic efficacy while dose adjustment should be considered in critically ill patients due to modified pharmacokinetic (PK) parameters and/or higher minimum inhibitory concentrations (MICs). This study aimed to assess pharmacodynamic (PD) target attainment considering both antibiotics serum concentrations and measured MICs in these patients. Method: A multicentric prospective open-label trial conducted in 11 French ICUs involved patients with Gram-negative bacilli (GNB) ventilator-associated pneumonia (VAP) confirmed by quantitative cultures. Results: We included 117 patients. Causative GNBs were P. aeruginosa (40%), Enterobacter spp. (23%), E. coli (20%), and Klebsiella spp. (16%). Hence, 117 (100%) patients received β-lactams, 65 (58%) aminoglycosides, and two (1.5%) fluoroquinolones. For β-lactams, 83% of the patients achieved a Cmin/MIC > 1 and 70% had a Cmin/MIC > 4. In the case of high creatinine clearance (CrCL > 100 mL/min/1.73 m2), 70.4% of the patients achieved a Cmin/MIC ratio > 1 versus 91% otherwise (p = 0.041), and 52% achieved a Cmin/MIC ratio > 4 versus 81% (p = 0.018). For aminoglycosides, 94% of the patients had a Cmax/MIC ratio > 8. Neither β-lactams nor aminoglycosides PK/PD parameters were associated clinical outcomes, but our data suggest a correlation between β-lactams Cmin/MIC and microbiological success. Conclusion: In our ICU patients treated for GNB VAP, using recommended antibiotic dosage led in most cases to PK/PD targets attainment for aminoglycosides and β-lactams. High creatinine clearance should encourage clinicians to focus on PK/PD issues.
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Affiliation(s)
- Olivier Pajot
- Victor Dupouy Hospital, Intensive Care Unit, F-95100 Argenteuil, France
- Correspondence: ; Tel.: +33-134232455
| | - Karim Lakhal
- Service d’Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, F-44093 Nantes, France
| | - Jérome Lambert
- Department of Biostatistics and Medical Information, APHP, Saint-Louis Hospital, F-75010 Paris, France
| | - Antoine Gros
- Medical-Surgical Intensive Care Unit, André Mignot Hospital, F-78150 Le Chesnay, France
| | - Cédric Bruel
- Medical and Surgical Intensive Care Unit, Paris Saint-Joseph Hospital Network, F-75014 Paris, France
| | - Thierry Boulain
- Intensive Care Unit, Orleans Regional Hospital, 14 Avenue de L’Hôpital CS 86709, CEDEX 02, F-45067 Orléans, France
| | - Denis Garot
- Service de Médecine Intensive Réanimation, Hôpital Bretonneau, CHU Tours, F-37000 Tours, France
| | - Vincent Das
- Service de Médecine Intensive Réanimation, Centre Hospitalier Intercommunal André Grégoire, F-93100 Montreuil, France
| | - Jean François Timsit
- AP-HP, Bichat Hospital, Medical and Infectious Diseases Intensive Care Unit (MI2), F-75018 Paris, France
| | - Charles Cerf
- Intensive Care Unit, Foch Hospital, F-92150 Suresnes, France
| | - Bertrand Souweine
- CHU Clermont-Ferrand, Service de Réanimation Médicale, F-63000 Clermont-Ferrand, France
| | - Cendrine Chaffaut
- Department of Biostatistics and Medical Information, APHP, Saint-Louis Hospital, F-75010 Paris, France
| | - Hervé Mentec
- Victor Dupouy Hospital, Intensive Care Unit, F-95100 Argenteuil, France
| | - Jean Ralph Zahar
- AP-HP, Hôpital Avicenne, Prévention du Risque Infectieux, GH Paris Seine Saint-Denis, F-93000 Bobigny, France
| | - Jean Paul Mira
- Department of Medical Intensive Care, Cochin University Hospital, F-75014 Paris, France
| | - Vincent Jullien
- Pharmacology Unit, University Sorbonne Paris Nord, Groupe Hospitalier Paris Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Hôpital Jean Verdier, F-93140 Bondy, France
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Hajage D, Combes A, Guervilly C, Lebreton G, Mercat A, Pavot A, Nseir S, Mekontso-Dessap A, Mongardon N, Mira JP, Ricard JD, Beurton A, Tachon G, Kontar L, Le Terrier C, Richard JC, Mégarbane B, Keogh RH, Belot A, Maringe C, Leyrat C, Schmidt M. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome Associated with COVID-19: An Emulated Target Trial Analysis. Am J Respir Crit Care Med 2022; 206:281-294. [PMID: 35533052 PMCID: PMC9890253 DOI: 10.1164/rccm.202111-2495oc] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 05/09/2022] [Indexed: 02/04/2023] Open
Abstract
Rationale: Whether patients with coronavirus disease (COVID-19) may benefit from extracorporeal membrane oxygenation (ECMO) compared with conventional invasive mechanical ventilation (IMV) remains unknown. Objectives: To estimate the effect of ECMO on 90-day mortality versus IMV only. Methods: Among 4,244 critically ill adult patients with COVID-19 included in a multicenter cohort study, we emulated a target trial comparing the treatment strategies of initiating ECMO versus no ECMO within 7 days of IMV in patients with severe acute respiratory distress syndrome (PaO2/FiO2 < 80 or PaCO2 ⩾ 60 mm Hg). We controlled for confounding using a multivariable Cox model on the basis of predefined variables. Measurements and Main Results: A total of 1,235 patients met the full eligibility criteria for the emulated trial, among whom 164 patients initiated ECMO. The ECMO strategy had a higher survival probability on Day 7 from the onset of eligibility criteria (87% vs. 83%; risk difference, 4%; 95% confidence interval, 0-9%), which decreased during follow-up (survival on Day 90: 63% vs. 65%; risk difference, -2%; 95% confidence interval, -10 to 5%). However, ECMO was associated with higher survival when performed in high-volume ECMO centers or in regions where a specific ECMO network organization was set up to handle high demand and when initiated within the first 4 days of IMV and in patients who are profoundly hypoxemic. Conclusions: In an emulated trial on the basis of a nationwide COVID-19 cohort, we found differential survival over time of an ECMO compared with a no-ECMO strategy. However, ECMO was consistently associated with better outcomes when performed in high-volume centers and regions with ECMO capacities specifically organized to handle high demand.
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Affiliation(s)
- David Hajage
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP
| | - Alain Combes
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixte de Recherche (UMRS) 1166, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de Médecine Intensive–Réanimation, Institut de Cardiologie, Assistance Publique–Hôpitaux de Paris (APHP), Hôpital Pitié-Salpêtrière, Département de Santé Publique, Centre de Pharmacoépidémiologie, Paris, France
| | - Christophe Guervilly
- Medecine Intensive Réanimation, Centre hospitalier Universitaire L’Hôpital Nord, Assistance Publique hôpitaux de Marseille, Marseille, France
- Aix-Marseille Université, Faculté de Médecine Centre d’Études et de Recherches sur les Services de Santé et qualité de vie EA 3279, Marseille, France
| | - Guillaume Lebreton
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixte de Recherche (UMRS) 1166, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de Médecine Intensive–Réanimation, Institut de Cardiologie, Assistance Publique–Hôpitaux de Paris (APHP), Hôpital Pitié-Salpêtrière, Département de Santé Publique, Centre de Pharmacoépidémiologie, Paris, France
- Medecine Intensive Réanimation, Centre hospitalier Universitaire L’Hôpital Nord, Assistance Publique hôpitaux de Marseille, Marseille, France
- Aix-Marseille Université, Faculté de Médecine Centre d’Études et de Recherches sur les Services de Santé et qualité de vie EA 3279, Marseille, France
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, APHP- Sorbonne University, Paris, France
| | - Alain Mercat
- Département de Médecine Intensive - Réanimation et Médecine Hyperbare, CHU d’Angers, Faculté de Santé, Université d’Angers, Angers, France
| | - Arthur Pavot
- Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Le Kremlin-Bicêtre, France
| | - Saad Nseir
- Médecine Intensive-Réanimation, CHU Lille, Inserm U1285, University of Lille, CNRS, UMR 8576, Unité de Glycobiologie Structurale et Fonctionnelle, Lille, France
| | - Armand Mekontso-Dessap
- AP-HP (Assistance Publique-Hôpitaux de Paris), Hôpitaux universitaires Henri Mondor, DMU Médecine, Service de Médecine Intensive Réanimation, INSERM Unité U955, Créteil, France
- UPEC (Université Paris Est Créteil), Faculté de Santé de Créteil, IMRB, GRC CARMAS, Créteil, France
| | - Nicolas Mongardon
- Service d'Anesthésie-Réanimation Chirurgicale, Hôpitaux Universitaires Henri Mondor, DMU CARE, Assistance Publique-Hôpitaux de Paris, Inserm U955 équipe 3, Faculté de Santé, Université Paris-Est Créteil, Créteil, France
| | - Jean Paul Mira
- Assistance Publique des Hôpitaux de Paris, Groupe Hospitalier Universitaire de Paris Centre, Hôpital Cochin, Médecine Intensive Réanimation; Paris Descartes Sorbonne Paris Cité University, Paris, France; Department of Infection, Immunity and Inflammation, Cochin Institute, Inserm U1016, Paris, France
| | - Jean-Damien Ricard
- Université de Paris, APHP, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, Colombes, France
| | - Alexandra Beurton
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S), and Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Guillaume Tachon
- Service de Médecine Intensive Réanimation, Hôpital Foch, Suresnes, France
| | - Loay Kontar
- Department of Intensive Care Medicine, CHU Amiens-Picardie, avenue Laennec, Amiens, France
| | - Christophe Le Terrier
- Division of Intensive Care, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jean Christophe Richard
- Service de Médecine Intensive–Réanimation, Hôpital de la Croix-Rousse–Hospices Civils de Lyon, Lyon, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, APHP, INSERM UMRS-1144, Paris University, Paris, France
| | - Ruth H. Keogh
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; and
| | - Aurélien Belot
- Inequalities in Cancer Outcomes Network, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Camille Maringe
- Inequalities in Cancer Outcomes Network, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Clémence Leyrat
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; and
| | - Matthieu Schmidt
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixte de Recherche (UMRS) 1166, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de Médecine Intensive–Réanimation, Institut de Cardiologie, Assistance Publique–Hôpitaux de Paris (APHP), Hôpital Pitié-Salpêtrière, Département de Santé Publique, Centre de Pharmacoépidémiologie, Paris, France
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Bougouin W, Dumas F, Lamhaut L, Marijon E, Carli P, Combes A, Pirracchio R, Aissaoui N, Karam N, Deye N, Sideris G, Beganton F, Jost D, Cariou A, Jouven X, Adnet F, Agostinucci JM, Aissaoui-Balanant N, Algalarrondo V, Alla F, Alonso C, Amara W, Annane D, Antoine C, Aubry P, Azoulay E, Beganton F, Benhamou D, Billon C, Bougouin W, Boutet J, Bruel C, Bruneval P, Cariou A, Carli P, Casalino E, Cerf C, Chaib A, Cholley B, Cohen Y, Combes A, Crahes M, Da Silva D, Das V, Demoule A, Denjoy I, Deye N, Dhonneur G, Diehl JL, Dinanian S, Domanski L, Dreyfuss D, Duboc D, Dubois-Rande JL, Dumas F, Empana JP, Extramiana F, Fartoukh M, Fieux F, Gabbas M, Gandjbakhch E, Geri G, Guidet B, Halimi F, Henry P, Hidden Lucet F, Jabre P, Jacob L, Joseph L, Jost D, Jouven X, Karam N, Kassim H, Lacotte J, Lahlou-Laforet K, Lamhaut L, Lanceleur A, Langeron O, Lavergne T, Lecarpentier E, Leenhardt A, Lellouche N, Lemiale V, Lemoine F, Linval F, Loeb T, Ludes B, Luyt CE, Maltret A, Mansencal N, Mansouri N, Marijon E, Marty J, Maury E, Maxime V, Megarbane B, Mekontso-Dessap A, Mentec H, Mira JP, Monnet X, Narayanan K, Ngoyi N, Perier MC, Piot O, Pirracchio R, Plaisance P, Plu I, Raux M, Revaux F, Ricard JD, Richard C, Riou B, Roussin F, Santoli F, Schortgen F, Sharifzadehgan A, Sideris G, Spaulding C, Teboul JL, Timsit JF, Tourtier JP, Tuppin P, Ursat C, Varenne O, Vieillard-Baron A, Voicu S, Wahbi K, Waldmann V. Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study. Eur Heart J 2019; 41:1961-1971. [DOI: 10.1093/eurheartj/ehz753] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 03/26/2019] [Accepted: 10/01/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes.
Methods and results
We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8–2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5–1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5–10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1–4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5–5.9; P = 0.002).
Conclusions
In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.
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Affiliation(s)
- Wulfran Bougouin
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, 56 rue Leblanc, 75787 Paris, France
- Medical-Surgical Intensive Care Unit, Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, 6 Avenue du Noyer Lambert, 91300 Massy, France
- Paris Sudden Death Expertise Center, 56 rue Leblanc, 75787 Paris, France
- AfterROSC network, 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Florence Dumas
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, 56 rue Leblanc, 75787 Paris, France
- Paris Sudden Death Expertise Center, 56 rue Leblanc, 75787 Paris, France
- Université Paris Descartes-Sorbonne Paris Cité, 12 Rue de l'École de Médecine, 75006 Paris, France
- Emergency Department, Cochin-Hotel-Dieu Hospital, APHP, 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Lionel Lamhaut
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, 56 rue Leblanc, 75787 Paris, France
- Paris Sudden Death Expertise Center, 56 rue Leblanc, 75787 Paris, France
- AfterROSC network, 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France
- Université Paris Descartes-Sorbonne Paris Cité, 12 Rue de l'École de Médecine, 75006 Paris, France
- Intensive Care Unit - SAMU 75, Necker-Enfants-Malades Hospital, APHP, 149 Rue de Sèvres, 75015 Paris, France
| | - Eloi Marijon
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, 56 rue Leblanc, 75787 Paris, France
- Paris Sudden Death Expertise Center, 56 rue Leblanc, 75787 Paris, France
- Université Paris Descartes-Sorbonne Paris Cité, 12 Rue de l'École de Médecine, 75006 Paris, France
- Cardiology Department, Georges Pompidou European Hospital, AP-HP, 20 Rue Leblanc, 75015 Paris, France
| | - Pierre Carli
- Université Paris Descartes-Sorbonne Paris Cité, 12 Rue de l'École de Médecine, 75006 Paris, France
- Intensive Care Unit - SAMU 75, Necker-Enfants-Malades Hospital, APHP, 149 Rue de Sèvres, 75015 Paris, France
| | - Alain Combes
- Medical-Surgical Intensive Care Unit, iCAN, Institute of Cardiometabolism and Nutrition, Pitié-Salpétrière Hospital, APHP, 47-83 Boulevard de l'Hôpital, 75013 Paris, France
| | - Romain Pirracchio
- Université Paris Descartes-Sorbonne Paris Cité, 12 Rue de l'École de Médecine, 75006 Paris, France
- Surgical ICU, Georges Pompidou European Hospital, AP-HP, 20 Rue Leblanc, 75015 Paris, France
| | - Nadia Aissaoui
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, 56 rue Leblanc, 75787 Paris, France
- Paris Sudden Death Expertise Center, 56 rue Leblanc, 75787 Paris, France
- AfterROSC network, 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France
- Université Paris Descartes-Sorbonne Paris Cité, 12 Rue de l'École de Médecine, 75006 Paris, France
- Medical ICU, Georges Pompidou European Hospital, AP-HP, 20 Rue Leblanc, 75015 Paris, France
| | - Nicole Karam
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, 56 rue Leblanc, 75787 Paris, France
- Paris Sudden Death Expertise Center, 56 rue Leblanc, 75787 Paris, France
- Université Paris Descartes-Sorbonne Paris Cité, 12 Rue de l'École de Médecine, 75006 Paris, France
- Cardiology Department, Georges Pompidou European Hospital, AP-HP, 20 Rue Leblanc, 75015 Paris, France
| | - Nicolas Deye
- AfterROSC network, 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France
- Medical ICU, Lariboisière Hospital, AP-HP, 2 Rue Ambroise Paré, 75010 Paris, France
| | - Georgios Sideris
- Cardiology Department, Lariboisière Hospital, AP-HP, 2 Rue Ambroise Paré, 75010 Paris, France
| | - Frankie Beganton
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, 56 rue Leblanc, 75787 Paris, France
- Paris Sudden Death Expertise Center, 56 rue Leblanc, 75787 Paris, France
| | - Daniel Jost
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, 56 rue Leblanc, 75787 Paris, France
- Paris Sudden Death Expertise Center, 56 rue Leblanc, 75787 Paris, France
- Brigade de Sapeurs Pompiers de Paris (BSPP), 1 Place Jules Renard, 75017 Paris, France
| | - Alain Cariou
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, 56 rue Leblanc, 75787 Paris, France
- Paris Sudden Death Expertise Center, 56 rue Leblanc, 75787 Paris, France
- AfterROSC network, 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France
- Université Paris Descartes-Sorbonne Paris Cité, 12 Rue de l'École de Médecine, 75006 Paris, France
- Medical Intensive Care Unit, Cochin Hospital, APHP, 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Xavier Jouven
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, 56 rue Leblanc, 75787 Paris, France
- Paris Sudden Death Expertise Center, 56 rue Leblanc, 75787 Paris, France
- Université Paris Descartes-Sorbonne Paris Cité, 12 Rue de l'École de Médecine, 75006 Paris, France
- Cardiology Department, Georges Pompidou European Hospital, AP-HP, 20 Rue Leblanc, 75015 Paris, France
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Abbara S, Domenech de Cellès M, Batista R, Mira JP, Poyart C, Poupet H, Casetta A, Kernéis S. Variable impact of an antimicrobial stewardship programme in three intensive care units: time-series analysis of 2012-2017 surveillance data. J Hosp Infect 2019; 104:150-157. [PMID: 31605739 DOI: 10.1016/j.jhin.2019.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/29/2019] [Accepted: 10/01/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Preprescription authorization (PPA) and postprescription review with feedback (PPRF) were successively implemented in 2012 and 2016 in our 1500-bed hospital. AIM The impact of PPA and PPRF on carbapenems use and resistance levels of Pseudomonas aeruginosa was assessed in three intensive care units (ICUs). METHODS Carbapenems use (in DDDs/1000 occupied bed-days) and resistance of P. aeruginosa (percentage of non-susceptible (I+R) isolates to imipenem and/or meropenem) were analysed using a controlled interrupted time-series method. Two periods were compared: 2012-2015 (PPA) and 2016-2017 (PPA+PPRF). Models were adjusted on the annual incidence of extended-spectrum β-lactamase-producing enterobacteriacae. FINDINGS Carbapenem use was stable over the PPA period in all ICUs, with a significant change of slope over the PPA+PPRF period only in ICU1 (β2 = -12.8, 95% confidence interval (CI) = -19.5 to -6.1). There was a switch from imipenem to meropenem during the PPA period in all three units. Resistances of P. aeruginosa were stable over the study period in ICU1 and ICU2, and significantly decreased over the PPA+PPRF period in ICU3 (β2 = -0.18, CI = -0.3 to -0.03). CONCLUSION In real-life conditions and with the same antimicrobial stewardship programme (AMSP) led by a single team, the impact of PPRF was heterogeneous between ICUs. Factors driving the impact of AMSPs should be further assessed in comparable settings through real-life data, to target where they could prove cost-effective.
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Affiliation(s)
- S Abbara
- INSERM, UMR 1181, Biostatistics, Biomathematics, Pharmacoepidemiology, and Infectious Diseases (B2PHI), Paris, France; Institut Pasteur, B2PHI, Paris, France; Versailles Saint-Quentin University, UMR 1181, B2PHI, Montigny-le-Bretonneux, France; Antimicrobial Stewardship Team, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre-Site Cochin, Paris, France.
| | - M Domenech de Cellès
- INSERM, UMR 1181, Biostatistics, Biomathematics, Pharmacoepidemiology, and Infectious Diseases (B2PHI), Paris, France; Institut Pasteur, B2PHI, Paris, France; Versailles Saint-Quentin University, UMR 1181, B2PHI, Montigny-le-Bretonneux, France
| | - R Batista
- Pharmacy, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre - Site Cochin, Paris, France
| | - J P Mira
- Medical Intensive Care Unit, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre - Site Cochin, Paris, France; Université Paris Descartes, Sorbonne Paris cité, Paris, France
| | - C Poyart
- Université Paris Descartes, Sorbonne Paris cité, Paris, France; Department of Bacteriology, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre - Site Cochin, Paris, France
| | - H Poupet
- Department of Bacteriology, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre - Site Cochin, Paris, France
| | - A Casetta
- Infection Control Team, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre - Site Cochin, Paris, France
| | - S Kernéis
- INSERM, UMR 1181, Biostatistics, Biomathematics, Pharmacoepidemiology, and Infectious Diseases (B2PHI), Paris, France; Institut Pasteur, B2PHI, Paris, France; Versailles Saint-Quentin University, UMR 1181, B2PHI, Montigny-le-Bretonneux, France; Université Paris Descartes, Sorbonne Paris cité, Paris, France; Antimicrobial Stewardship Team, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre-Site Cochin, Paris, France
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7
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de Roquetaillade C, Llitjos JF, Paul M, Guillemet L, Hadj Salem OB, Mira JP, Cariou A. Diabetic ketoacidosis, a common disease with life-threatening pitfalls. Acute Med 2019; 18:189-191. [PMID: 31536057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Diabetic ketoacidosis (DKA) is a common cause for admission in Emergency Department. Its treatment is well defined. Nevertheless, in some cases, type I diabetes combines with auto-immune polyendocrine syndrome, which can carry life-threatening consequences. Here we report the case of a young man with inaugural DKA who exhibited ventricular fibrillation and cardiac arrest due to significant hypokalaemia, following undiagnosed thyrotoxicosis with periodic paralysis.
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Affiliation(s)
- C de Roquetaillade
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaires Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France and Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'école de Méédecine, 75006 Paris,France
| | - J F Llitjos
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaires Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France and Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'école de Méédecine, 75006 Paris,France
| | - M Paul
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaires Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France and Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'école de Méédecine, 75006 Paris,France
| | - L Guillemet
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaires Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France and Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'école de Méédecine, 75006 Paris,France
| | - O B Hadj Salem
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaires Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France and Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'école de Méédecine, 75006 Paris,France
| | - J P Mira
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaires Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France and Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'école de Méédecine, 75006 Paris,France
| | - A Cariou
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaires Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France and Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'école de Méédecine, 75006 Paris,France
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8
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Garrouste-Orgeas M, Flahault C, Fasse L, Ruckly S, Amdjar-Badidi N, Argaud L, Badie J, Bazire A, Bige N, Boulet E, Bouadma L, Bretonnière C, Floccard B, Gaffinel A, de Forceville X, Grand H, Halidfar R, Hamzaoui O, Jourdain M, Jost PH, Kipnis E, Large A, Lautrette A, Lesieur O, Maxime V, Mercier E, Mira JP, Monseau Y, Parmentier-Decrucq E, Rigaud JP, Rouget A, Santoli F, Simon G, Tamion F, Thieulot-Rolin N, Thirion M, Valade S, Vinatier I, Vioulac C, Bailly S, Timsit JF. The ICU-Diary study: prospective, multicenter comparative study of the impact of an ICU diary on the wellbeing of patients and families in French ICUs. Trials 2017; 18:542. [PMID: 29141694 PMCID: PMC5688734 DOI: 10.1186/s13063-017-2283-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 10/24/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Post-intensive care syndrome includes the multiple consequences of an intensive care unit (ICU) stay for patients and families. It has become a new challenge for intensivists. Prevention programs have been disappointing, except for ICU diaries, which report the patient's story in the ICU. However, the effectiveness of ICU diaries for patients and families is still controversial, as the interpretation of the results of previous studies was open to criticism hampering an expanded use of the diary. The primary objective of the study is to evaluate the post-traumatic stress syndrome in patients. The secondary objectives are to evaluate the post-traumatic stress syndrome in families, anxiety and depression symptoms in patients and families, and the recollected memories of patients. Endpoints will be evaluated 3 months after ICU discharge or death. METHODS A prospective, multicenter, randomized, assessor-blind comparative study of the effect of an ICU diary on patients and families. We will compare two groups: one group with an ICU diary written by staff and family and given to the patient at ICU discharge or to the family in case of death, and a control group without any ICU diary. Each of the 35 participating centers will include 20 patients having at least one family member who will likely visit the patient during their ICU stay. Patients must be ventilated within 48 h after ICU admission and not have any previous chronic neurologic or acute condition responsible for cognitive impairments that would hamper their participation in a phone interview. Three months after ICU discharge or death of the patient, a psychologist will contact the patient and family by phone. Post-traumatic stress syndrome will be evaluated using the Impact of Events Scale-Revised questionnaire, anxiety and depression symptoms using the Hospital Anxiety and Depression Scale questionnaire, both in patients and families, and memory recollection using the ICU Memory Tool Questionnaire in patients. The content of a randomized sample of diaries of each center will be analyzed using a grid. An interview of the patients in the intervention arm will be conducted 6 months after ICU discharge to analyze in depth how they use the diary. DISCUSSION This study will provide new insights on the impact of ICU diaries on post-traumatic stress disorders in patients and families after an ICU stay. TRIAL REGISTRATION ClinicalTrial.gov, ID: NCT02519725 . Registered on 13 July 2015.
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Affiliation(s)
- Maïté Garrouste-Orgeas
- Infection, Antimicrobials, Modelling, Evolution (IAME), UMR 1137, INSERM and Paris Diderot University, Department of Biostatistics - HUPNVS - AP-HP, UFR de Médecine - Bichat University Hospital, Paris, France. .,Department of Biostatistics, Outcomerea, Paris, France. .,Medical unit, French British Hospital Institute, Levallois-Perret, France.
| | - Cécile Flahault
- Psychology laboratory and work process, Paris Descartes University, Paris, France
| | - Léonor Fasse
- Laboratoire Psy-DREPI EA-7458, Bourgogne Franche Comté University, Dijon, France
| | - Stéphane Ruckly
- Infection, Antimicrobials, Modelling, Evolution (IAME), UMR 1137, INSERM and Paris Diderot University, Department of Biostatistics - HUPNVS - AP-HP, UFR de Médecine - Bichat University Hospital, Paris, France.,Department of Biostatistics, Outcomerea, Paris, France
| | | | - Laurent Argaud
- Medical ICU, Edouard Herriot University Hospital, Lyon, France
| | - Julio Badie
- Medical-Surgical ICU, General Hospital Belfort-Montbeliard, Belfort, France
| | - Amélie Bazire
- Medical ICU, La Cavale Blanche University Hospital, Brest, France
| | - Naike Bige
- Medical ICU, Saint Antoine University Hospital, Paris, France
| | - Eric Boulet
- Medical ICU, Beaumont General Hospital, Beaumont, France
| | - Lila Bouadma
- Infection, Antimicrobials, Modelling, Evolution (IAME), UMR 1137, INSERM and Paris Diderot University, Department of Biostatistics - HUPNVS - AP-HP, UFR de Médecine - Bichat University Hospital, Paris, France.,Medical ICU, Bichat University Hospital, Paris, France
| | - Cédric Bretonnière
- Medical ICU, Nantes University Hospital, Nantes, France.,EA3826, Laboratory of clinical and experimental therapeutics of infections, University of Nantes, Nantes, France
| | - Bernard Floccard
- Medical ICU, Hospices Civils de Lyon, Edouard Herriot University Hospital, Lyon, France
| | - Alain Gaffinel
- Medical-Surgical ICU, Gustave Roussy Cancer Campus, Villejuif, France
| | | | - Hubert Grand
- Medical-Surgical ICU, Hospital Robert Boulin, Libourne, France
| | - Rebecca Halidfar
- Medical ICU, Albert Michallon University Hospital, Grenoble, France
| | - Olfa Hamzaoui
- Medical ICU, University Hospital Paris-Sud, Beclère University Hospital, Clamart, France
| | - Mercé Jourdain
- Lille University, Inserm U1190, Lille, France.,Group of medical ICUs, Lille University Hospital, Lille, France
| | - Paul-Henri Jost
- Surgical ICU, Henri Mondor University Hospital, Créteil, France
| | - Eric Kipnis
- Surgical ICU, Lille University Hospital, Lille, France
| | - Audrey Large
- Medical ICU, François Mitterrand University Hospital, Dijon, France
| | - Alexandre Lautrette
- Medical ICU, Gabriel-Montpied University Hospital, Clermont Ferrand, France.,LMGE UMR CNRS 6023, University of Clermont-Ferrand, Clermont Ferrand, France
| | - Olivier Lesieur
- Medical-Surgical ICU, General Hospital, La Rochelle, France.,EA 4569, University Paris Descartes, Paris, France
| | - Virginie Maxime
- Medical ICU, Raymond Poincaré University Hospital, Garches, France
| | - Emmanuelle Mercier
- CRICS group, Medical-Surgical ICU, Tours University Hospital, Tours, France
| | | | | | | | | | - Antoine Rouget
- Medical-Surgical ICU, Rangueil University Hospital, Toulouse, France
| | - François Santoli
- Medical ICU, General Hospital Robert Ballanger, Aulnay-Sous-Bois, France
| | - Georges Simon
- Medical-Surgical ICU, General Hospital, Troyes, France
| | - Fabienne Tamion
- Medical ICU, University medical center, Rouen, France.,INSERM U-1096, University of Rouen, Rouen, France
| | | | - Marina Thirion
- Medical-Surgical ICU, General Hospital Victor Dupouy, Argenteuil, France
| | | | | | - Christel Vioulac
- Psychology laboratory and work process, Paris Descartes University, Paris, France
| | - Sebastien Bailly
- Infection, Antimicrobials, Modelling, Evolution (IAME), UMR 1137, INSERM and Paris Diderot University, Department of Biostatistics - HUPNVS - AP-HP, UFR de Médecine - Bichat University Hospital, Paris, France
| | - Jean-François Timsit
- Infection, Antimicrobials, Modelling, Evolution (IAME), UMR 1137, INSERM and Paris Diderot University, Department of Biostatistics - HUPNVS - AP-HP, UFR de Médecine - Bichat University Hospital, Paris, France.,Department of Biostatistics, Outcomerea, Paris, France.,Medical ICU, Bichat University Hospital, Paris, France
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9
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Lascarrou JB, Boisrame-Helms J, Bailly A, Le Thuaut A, Kamel T, Mercier E, Ricard JD, Lemiale V, Colin G, Mira JP, Meziani F, Messika J, Dequin PF, Boulain T, Azoulay E, Champigneulle B, Reignier J. Video Laryngoscopy vs Direct Laryngoscopy on Successful First-Pass Orotracheal Intubation Among ICU Patients: A Randomized Clinical Trial. JAMA 2017; 317:483-493. [PMID: 28118659 DOI: 10.1001/jama.2016.20603] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
IMPORTANCE In the intensive care unit (ICU), orotracheal intubation can be associated with increased risk of complications because the patient may be acutely unstable, requiring prompt intervention, often by a practitioner with nonexpert skills. Video laryngoscopy may decrease this risk by improving glottis visualization. OBJECTIVE To determine whether video laryngoscopy increases the frequency of successful first-pass orotracheal intubation compared with direct laryngoscopy in ICU patients. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 371 adults requiring intubation while being treated at 7 ICUs in France between May 2015 and January 2016; there was 28 days of follow-up. INTERVENTIONS Intubation using a video laryngoscope (n = 186) or direct laryngoscopy (n = 185). All patients received general anesthesia. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of patients with successful first-pass intubation. The secondary outcomes included time to successful intubation and mild to moderate and severe life-threatening complications. RESULTS Among 371 randomized patients (mean [SD] age, 62.8 [15.8] years; 136 [36.7%] women), 371 completed the trial. The proportion of patients with successful first-pass intubation did not differ significantly between the video laryngoscopy and direct laryngoscopy groups (67.7% vs 70.3%; absolute difference, -2.5% [95% CI, -11.9% to 6.9%]; P = .60). The proportion of first-attempt intubations performed by nonexperts (primarily residents, n = 290) did not differ between the groups (84.4% with video laryngoscopy vs 83.2% with direct laryngoscopy; absolute difference 1.2% [95% CI, -6.3% to 8.6%]; P = .76). The median time to successful intubation was 3 minutes (range, 2 to 4 minutes) for both video laryngoscopy and direct laryngoscopy (absolute difference, 0 [95% CI, 0 to 0]; P = .95). Video laryngoscopy was not associated with life-threatening complications (24/180 [13.3%] vs 17/179 [9.5%] for direct laryngoscopy; absolute difference, 3.8% [95% CI, -2.7% to 10.4%]; P = .25). In post hoc analysis, video laryngoscopy was associated with severe life-threatening complications (17/179 [9.5%] vs 5/179 [2.8%] for direct laryngoscopy; absolute difference, 6.7% [95% CI, 1.8% to 11.6%]; P = .01) but not with mild to moderate life-threatening complications (10/181 [5.4%] vs 14/181 [7.7%]; absolute difference, -2.3% [95% CI, -7.4% to 2.8%]; P = .37). CONCLUSIONS AND RELEVANCE Among patients in the ICU requiring intubation, video laryngoscopy compared with direct laryngoscopy did not improve first-pass orotracheal intubation rates and was associated with higher rates of severe life-threatening complications. Further studies are needed to assess the comparative effectiveness of these 2 strategies in different clinical settings and among operators with diverse skill levels. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02413723.
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Affiliation(s)
| | - Julie Boisrame-Helms
- Service de Réanimation Médicale, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France3EA 7293, Fédération de Médecine Translationnelle de Strasbourg, Faculté de Médecine, Université de Strasbourg, Strasbourg, France
| | - Arthur Bailly
- Medical-Surgical Intensive Care Unit, District Hospital Centre, La Roche-sur-Yon, France
| | - Aurelie Le Thuaut
- Clinical Research Unit, District Hospital Centre, La Roche-sur-Yon, France5Delegation a la Recherche Clinique et a l'Innovation-CHU Hotel Dieu, Nantes, France
| | - Toufik Kamel
- Medical Intensive Care Unit, Regional Hospital Centre, Orleans, France
| | | | - Jean-Damien Ricard
- AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, F-92700, Colombes, France9INSERM, IAME 1137, Sorbonne Paris Cité, F-75018, Paris, France
| | - Virginie Lemiale
- APHP Hôpital Saint Louis, Service de Réanimation Médicale, Paris, France
| | - Gwenhael Colin
- Medical-Surgical Intensive Care Unit, District Hospital Centre, La Roche-sur-Yon, France
| | - Jean Paul Mira
- Medical Intensive Care Unit, Cochin University Hospital Centre, Paris, France
| | - Ferhat Meziani
- Service de Réanimation Médicale, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France3EA 7293, Fédération de Médecine Translationnelle de Strasbourg, Faculté de Médecine, Université de Strasbourg, Strasbourg, France
| | - Jonathan Messika
- AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, F-92700, Colombes, France9INSERM, IAME 1137, Sorbonne Paris Cité, F-75018, Paris, France
| | | | - Thierry Boulain
- Medical Intensive Care Unit, Regional Hospital Centre, Orleans, France
| | - Elie Azoulay
- APHP Hôpital Saint Louis, Service de Réanimation Médicale, Paris, France
| | | | - Jean Reignier
- Medical Intensive Care Unit, University Hospital Centre, Nantes, France13EA 3826, Clinical and Experimental Treatments for Infections, University of Medicine, Nantes, France
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Champigneulle B, Jamme M, Knebelmann B, Mochel F, Mira JP. Unexplicated hyperammonemic encephalopathy: remember the old urinary diversions! Acta Neurol Belg 2016; 116:677-678. [PMID: 26830648 DOI: 10.1007/s13760-016-0606-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 01/14/2016] [Indexed: 11/27/2022]
Affiliation(s)
- B Champigneulle
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.
- Paris Descartes University, Sorbonne Paris Cité, Paris, France.
| | - M Jamme
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - B Knebelmann
- Paris Descartes University, Sorbonne Paris Cité, Paris, France
- Departement of Nephrology, Necker University Hospital, AP-HP, Paris, France
| | - F Mochel
- Departement of Genetics, La Pitié-Salpêtrière University Hospital, AP-HP, Paris, France
- Neurometabolic Unit, La Pitié-Salpêtrière University Hospital, AP-HP, Paris, Paris, France
- Pierre et Marie Curie University, Paris, France
| | - J P Mira
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
- Paris Descartes University, Sorbonne Paris Cité, Paris, France
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Montravers P, Perrigault PF, Timsit JF, Mira JP, Lortholary O, Leroy O, Gangneux JP, Guillemot D, Bensoussan C, Bailly S, Azoulay E, Constantin JM, Dupont H. Antifungal therapy for patients with proven or suspected Candida peritonitis: Amarcand2, a prospective cohort study in French intensive care units. Clin Microbiol Infect 2016; 23:117.e1-117.e8. [PMID: 27746395 DOI: 10.1016/j.cmi.2016.10.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/04/2016] [Accepted: 10/05/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The clinical characteristics and prognosis of patients treated for Candida peritonitis (CP) were compared according to the type of systemic antifungal therapy (SAT), empiric (EAF) or targeted (TAF) therapies, and the final diagnosis of infection. METHODS Patients in intensive care units (ICU) treated for CP were selected among the AmarCAND2 cohort, to compare patients receiving EAF for unconfirmed suspicion of CP (EAF/nonCP), to those with suspected secondarily confirmed CP (EAF/CP), or with primarily proven CP receiving TAF. RESULTS In all, 279 patients were evaluated (43.4% EAF/nonCP, 29.7% EAF/CP and 25.8% TAF patients). At SAT initiation, the severity of illness was similar among EAF/nonCP and EAF/CP patients, lower among TAF patients (median Simplified Acute Physiology Score II (SAPS II) 49 and 51 versus 35, respectively; p 0.001). Candida albicans was involved in 67%, Candida glabrata in 15.6%. All strains were susceptible to echinocandin; 84% to fluconazole. Echinocandin was administered to 51.2% EAF/nonCP, 49% EAF/CP and 40% TAF patients. At day 28, 72%, 76% and 75% of EAF/nonCP, EAF/CP and TAF patients, respectively, were alive. An increased mortality was observed in patients with a Sequential Organ Failure Assessment (SOFA) score <7 if SAT was delayed by ≥6 days (p 0.04). Healthcare-associated CP (OR 3.82, 95% CI 1.52-9.64, p 0.004), SOFA ≥8 at ICU admission (OR 2.61, 95% CI 1.08-6.34; p 0.03), and SAPS II ≥45 at SAT initiation (OR 5.08, 95% CI 1.04-12.67; p 0.001) impacted the 28-day mortality. CONCLUSIONS In summary, only 56.6% of ICU patients receiving SAT had CP. Most strains were susceptible to SAT. A similar 28-day mortality rate was observed among groups; the late administration of SAT significantly worsened the prognosis of patients with less severe CP.
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Affiliation(s)
- P Montravers
- Paris Diderot Sorbonne Cite University, and Anesthesiology and Critical Care Medicine, Bichat-Claude Bernard University Hospital, HUPNSV, AP-HP, Paris, France.
| | - P F Perrigault
- Medical-surgical ICU, Montpellier University Hospital, Montpellier, France
| | - J F Timsit
- Medical ICU, Paris Diderot University, and Bichat University Hospital, HUPNVS, AP-HP, Paris, France
| | - J P Mira
- Medical ICU, Cochin University Hospital, HUPC, AP-HP, and Paris Descartes, Sorbonne Paris Cité University, Paris, France
| | - O Lortholary
- University Paris Descartes, Necker Pasteur Centre for Infectious Diseases, HUNEM, AP-HP, IHU Imagine, Paris, France; Pasteur Institute, National Reference Centre for Invasive Mycoses and Antifungals, CNRS URA3012, Paris, France
| | - O Leroy
- Medical ICU, Chatilliez Hospital, Tourcoing, France
| | - J P Gangneux
- Mycology, Rennes University Hospital, Rennes, France
| | - D Guillemot
- Inserm UMR 1181 « Biostatistics, Biomathematics, Pharmaco-epidemiology and Infectious Diseases » (B2PHI), F-75015 Paris, France
| | - C Bensoussan
- Medical Affairs, Therapy Area Hospital, MSD France, Courbevoie, France
| | - S Bailly
- Inserm UMR 1137 - IAME Team 5 - DeSCID: Decision SCiences in Infectious Diseases, Control and Care INSERM/Paris Diderot, Sorbonne Paris Cité University, Paris, France
| | - E Azoulay
- Medical ICU, Saint-Louis University Hospital, HUSLLFW, AP-HP, Paris, France
| | - J M Constantin
- Perioperative Medicine Department, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - H Dupont
- Surgical ICU, Amiens University Hospital, Amiens, France
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Champigneulle B, Geri G, Bougouin W, Dumas F, Arnaout M, Zafrani L, Pène F, Charpentier J, Mira JP, Cariou A. Hypoxic hepatitis after out-of-hospital cardiac arrest: Incidence, determinants and prognosis. Resuscitation 2016; 103:60-65. [PMID: 27068401 DOI: 10.1016/j.resuscitation.2016.03.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 03/15/2016] [Accepted: 03/30/2016] [Indexed: 01/04/2023]
Abstract
AIM Hypoxic hepatitis (HH) may complicate the course of resuscitated out-of-hospital cardiac arrest (OHCA) patients admitted in intensive care unit (ICU). Aims of this study were to assess the prevalence of HH, and to describe the factors associated with HH occurrence and outcome. METHODS We conducted an observational study over a 6-year period (2009-2014) in a cardiac arrest center. All non-traumatic OHCA patients admitted in the ICU after return of spontaneous circulation (ROSC) and who survived more than 24h were included. HH was defined as an elevation of alanine aminotransferase over 20 times the upper limit of normal during the first 72h after OHCA. Factors associated with HH and ICU mortality were picked up by multivariate logistic regression. RESULTS Among the 632 OHCA patients included in the study, HH was observed in 72 patients (11.4% (95% CI: 9.0%, 14.1%)). In multivariate analysis, time from collapse to ROSC [OR 1.02 per additional minute; 95% CI (1.00, 1.04); p=0.01], male gender [OR 0.53; 95% CI (0.29, 0.95); p=0.03] and initial shockable rhythm [OR 0.35; 95% CI (0.19, 0.65); p<0.01] were associated with HH occurrence. After adjustment for confounding factors, HH was associated with ICU mortality [OR 4.39; 95% CI (1.71, 11.26); p<0.01] and this association persisted even if occurrence of a post-CA shock was considered in the statistical model [OR 3.63; 95% CI (1.39, 9.48); p=0.01]. CONCLUSIONS HH is not a rare complication after OHCA. This complication is mainly triggered by the duration of resuscitation and is associated with increased ICU mortality.
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Affiliation(s)
- B Champigneulle
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France.
| | - G Geri
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; INSERM U970 Sudden Death Expertise Center, Paris Cardiovascular Research Center, Paris, France
| | - W Bougouin
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; INSERM U970 Sudden Death Expertise Center, Paris Cardiovascular Research Center, Paris, France
| | - F Dumas
- Paris Descartes University, Sorbonne Paris Cité, Paris, France; Emergency Department, Cochin University Hospital, AP-HP, Paris, France; INSERM U970 Sudden Death Expertise Center, Paris Cardiovascular Research Center, Paris, France
| | - M Arnaout
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - L Zafrani
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - F Pène
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - J Charpentier
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - J P Mira
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - A Cariou
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France; INSERM U970 Sudden Death Expertise Center, Paris Cardiovascular Research Center, Paris, France
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Llitjos JF, Daviaud F, Grimaldi D, Legriel S, Georges JL, Guerot E, Bedos JP, Fagon JY, Charpentier J, Mira JP. Ilio-psoas hematoma in the intensive care unit: a multicentric study. Ann Intensive Care 2016; 6:8. [PMID: 26782681 PMCID: PMC4717128 DOI: 10.1186/s13613-016-0106-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 01/04/2016] [Indexed: 02/06/2023] Open
Abstract
Background
Clinical features and outcomes of patients with spontaneous ilio-psoas hematoma (IPH) in intensive care units (ICUs) are poorly documented. The objectives of this study were to determine epidemiological, clinical, biological and management characteristics of ICU patients with IPH. Methods
We conducted a retrospective multicentric study in three French ICUs from January 2006 to December 2014. We included IPH diagnosed both at admission and during ICU stay. Surgery and embolization were available 24 h a day for each center, and therapeutic decisions were undertaken after pluridisciplinary discussion. All IPHs were diagnosed using CT scan. Results During this period, we identified 3.01 cases/1000 admissions. The mortality rate of the 77 included patients was 30 %. In multivariate analysis, we observed that mortality was independently associated with SAPS II (OR 1.1, 95 % CI [1.013–1.195], p = 0.02) and with the presence of hemorrhagic shock (OR 67.1, 95 % CI [2.6–1691], p = 0.01). We found IPH was related to anticoagulation therapy in 56 cases (72 %), with guideline-concordant reversal performed in 33 % of patients. We did not found any association between anticoagulant therapy type and outcome. Conclusion We found IPH is an infrequent disease, with a high mortality rate of 30 %, mostly related to anticoagulation therapy and usually affecting the elderly. Management of anticoagulation-related IPH includes a high rate of no reversal of 38 %.
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Affiliation(s)
- J F Llitjos
- Medical Intensive Care Unit, Cochin Hospital, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France. .,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France.
| | - F Daviaud
- Medical Intensive Care Unit, Cochin Hospital, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France
| | - D Grimaldi
- Medical Intensive Care Unit, Cochin Hospital, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France
| | - S Legriel
- Intensive Care Unit, Hôpital de Versailles - Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - J L Georges
- Cardiology, Hôpital de Versailles - Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - E Guerot
- Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France.,Medical Intensive Care Unit, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - J P Bedos
- Intensive Care Unit, Hôpital de Versailles - Site André Mignot, 177 rue de Versailles, 78150, Le Chesnay Cedex, France
| | - J Y Fagon
- Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France.,Medical Intensive Care Unit, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - J Charpentier
- Medical Intensive Care Unit, Cochin Hospital, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France
| | - J P Mira
- Medical Intensive Care Unit, Cochin Hospital, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, 15 rue de l'Ecole de Médecine, 75006, Paris, France
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Debue AS, Charpentier J, Arnaout M, Busson J, Boulila C, Cabon S, Dhumeaux J, Ericher N, Lefort S, Lucas P, Marincamp A, Reffiena M, Cariou A, Mira JP, Chiche JD. Are Daily Sedation Stops Safe in a Medical Icu? Intensive Care Med Exp 2015. [PMCID: PMC4798311 DOI: 10.1186/2197-425x-3-s1-a26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Cabon S, Debue AS, Charpentier J, Asselie N, Brunie C, Ericher N, Garcia J, Gidel L, Lanclas H, Pileyre A, Mira JP, Pène F. Caregivers perception of the implementation of an ICU diary. Intensive Care Med Exp 2015. [PMCID: PMC4797777 DOI: 10.1186/2197-425x-3-s1-a653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Dumas F, Bougouin W, Geri G, Lamhaut L, Rosencher J, Pène F, Chiche JD, Varenne O, Carli P, Jouven X, Mira JP, Spaulding C, Cariou A. Is early PCI associated with a clinical benefit in post-cardiac arrest patients without STEMI pattern? Insights from the Parisian registry (PROCAT II). Resuscitation 2015. [DOI: 10.1016/j.resuscitation.2015.09.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Bougouin W, Dumas F, Marijon E, Geri G, Champigneulle B, Chiche JD, Varenne O, Spaulding C, Mira JP, Jouven X, Cariou A. Gender-related differences and similarities in eligibility for coronary reperfusion and outcome after out-of-hospital cardiac arrest. Intensive Care Med Exp 2015. [PMCID: PMC4797894 DOI: 10.1186/2197-425x-3-s1-a193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Bailly S, Leroy O, Montravers P, Constantin JM, Dupont H, Guillemot D, Lortholary O, Mira JP, Perrigault PF, Gangneux JP, Azoulay E, Timsit JF. ANTIFUNGAL DE-ESCALATION IS SAFE IN CRITICALLY ILL PATIENTS TREATED FOR SUSPECTED OR DOCUMENTED INVASIVE CANDIDIASIS. DATA FROM THE AMARCAND2 STUDY. Intensive Care Med Exp 2015. [PMCID: PMC4797565 DOI: 10.1186/2197-425x-3-s1-a5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Constantin J, Timsit JF, Gangneux JP, Mira JP, Montravers P, Dupont H, Perrigault P, Lortholary O, Azoulay E, Leroy O. Epidemiological cohort study of systemic antifungal therapy for suspected or confirmed invasive candidiasis in the ICU: the Amarcand2 study. Crit Care 2015. [PMCID: PMC4472423 DOI: 10.1186/cc14191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Bouglé A, Max A, Mongardon N, Grimaldi D, Pène F, Rousseau C, Chiche JD, Bedos JP, Vicaut E, Mira JP. Protective effects of FCGR2A polymorphism in invasive pneumococcal diseases. Crit Care 2012; 16. [PMCID: PMC3504810 DOI: 10.1186/cc11696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
| | - A Max
- Hôpital Cochin, Paris, France
| | | | | | - F Pène
- Hôpital Cochin, Paris, France
| | - C Rousseau
- Institut Cochin, INSERM U1016/CNRS UMR8104, Paris, France
| | | | - JP Bedos
- Hôpital André Mignot, Le Chesnay, France
| | - E Vicaut
- Hôpital Lariboisière, Paris, France
| | - JP Mira
- Hôpital Cochin, Paris, France
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Grimaldi D, Louis S, Pène F, Sirgo G, Rousseau C, Claessens YE, Vimeux L, Cariou A, Mira JP, Hosmalin A, Chiche JD. Profound and persistent decrease of circulating dendritic cells is associated with ICU-acquired infection in patients with septic shock. Intensive Care Med 2011; 37:1438-46. [PMID: 21805160 DOI: 10.1007/s00134-011-2306-1] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Accepted: 05/27/2011] [Indexed: 01/23/2023]
Abstract
PURPOSE Septic shock induces a decrease in dendritic cells (DCs) that may contribute to sepsis-induced immunosuppression. We analyzed the time course of circulating DCs in patients with septic shock and its relation to susceptibility to intensive care unit (ICU)-acquired infections. METHODS We enrolled adult patients with septic shock (n = 43), non-septic shock (n = 29), and with sepsis without organ dysfunction (n = 16). Healthy controls (n = 16) served as reference. Blood samples were drawn on the day of shock (day 1), then after 3 and 7 days. Myeloid (mDC) and plasmacytoid (pDC) DCs were counted by flow cytometry. Cell surface HLA-DR expression was analyzed in both DC subsets. RESULTS At day 1, median mDC and pDC counts were dramatically lower in septic shock patients as compared to healthy controls (respectively, 835 mDCs and 178 pDCs/ml vs. 19,342 mDCs and 6,169 pDCs/ml; P < 0.0001) but also to non-septic shock and sepsis patients (P < 0.0001). HLA-DR expression was decreased in both mDCs and pDCS within the septic shock group as compared to healthy controls. DC depletion was sustained for at least 7 days in septic shock patients. Among them, 10/43 developed ICU-acquired infections after a median of 9 [7.5-11] days. At day 7, mDC counts increased in patients devoid of secondary infections, whereas they remained low in those who subsequently developed ICU-acquired infections. CONCLUSION Septic shock is associated with profound and sustained depletion of circulating DCs. The persistence of low mDC counts is associated with the development of ICU-acquired infections, suggesting that DC depletion is a functional feature of sepsis-induced immunosuppression.
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Affiliation(s)
- D Grimaldi
- Medical Intensive Care Unit, Hôpital Cochin, AP-HP, 27 rue du Faubourg Saint Jacques, 75014 Paris, France
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Lafanechère A, Pène F, Goulenok C, Delahaye A, Mallet V, Choukroun G, Chiche JD, Mira JP, Cariou A. Changes in aortic blood flow induced by passive leg raising predict fluid responsiveness in critically ill patients. Crit Care 2007; 10:R132. [PMID: 16970817 PMCID: PMC1751046 DOI: 10.1186/cc5044] [Citation(s) in RCA: 147] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2006] [Revised: 08/28/2006] [Accepted: 09/13/2006] [Indexed: 02/21/2023] Open
Abstract
Introduction Esophageal Doppler provides a continuous and non-invasive estimate of descending aortic blood flow (ABF) and corrected left ventricular ejection time (LVETc). Considering passive leg raising (PLR) as a reversible volume expansion (VE), we compared the relative abilities of PLR-induced ABF variations, LVETc and respiratory pulsed pressure variations (ΔPP) to predict fluid responsiveness. Methods We studied 22 critically ill patients in acute circulatory failure in the supine position, during PLR, back to the supine position and after two consecutive VEs of 250 ml of saline. Responders were defined by an increase in ABF induced by 500 ml VE of more than 15%. Results Ten patients were responders and 12 were non-responders. In responders, the increase in ABF induced by PLR was similar to that induced by a 250 ml VE (16% versus 20%; p = 0.15). A PLR-induced increase in ABF of more than 8% predicted fluid responsiveness with a sensitivity of 90% and a specificity of 83%. Corresponding positive and negative predictive values (PPV and NPV, respectively) were 82% and 91%, respectively. A ΔPP threshold value of 12% predicted fluid responsiveness with a sensitivity of 70% and a specificity of 92%. Corresponding PPV and NPV were 87% and 78%, respectively. A LVETc of 245 ms or less predicted fluid responsiveness with a sensitivity of 70%, and a specificity of 67%. Corresponding PPV and NPV were 60% and 66%, respectively. Conclusion The PLR-induced increase in ABF and a ΔPP of more than 12% offer similar predictive values in predicting fluid responsiveness. An isolated basal LVETc value is not a reliable criterion for predicting response to fluid loading.
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Affiliation(s)
- A Lafanechère
- Medical Intensive Care Unit, Cochin Hospital, APHP, Université Paris Descartes, 27, rue du Faubourg Saint Jacques, 75679 Paris Cedex 14, France
| | - F Pène
- Medical Intensive Care Unit, Cochin Hospital, APHP, Université Paris Descartes, 27, rue du Faubourg Saint Jacques, 75679 Paris Cedex 14, France
| | - C Goulenok
- Medical Intensive Care Unit, Cochin Hospital, APHP, Université Paris Descartes, 27, rue du Faubourg Saint Jacques, 75679 Paris Cedex 14, France
| | - A Delahaye
- Medical Intensive Care Unit, Cochin Hospital, APHP, Université Paris Descartes, 27, rue du Faubourg Saint Jacques, 75679 Paris Cedex 14, France
| | - V Mallet
- Medical Intensive Care Unit, Cochin Hospital, APHP, Université Paris Descartes, 27, rue du Faubourg Saint Jacques, 75679 Paris Cedex 14, France
| | - G Choukroun
- Medical Intensive Care Unit, Cochin Hospital, APHP, Université Paris Descartes, 27, rue du Faubourg Saint Jacques, 75679 Paris Cedex 14, France
| | - JD Chiche
- Medical Intensive Care Unit, Cochin Hospital, APHP, Université Paris Descartes, 27, rue du Faubourg Saint Jacques, 75679 Paris Cedex 14, France
| | - JP Mira
- Medical Intensive Care Unit, Cochin Hospital, APHP, Université Paris Descartes, 27, rue du Faubourg Saint Jacques, 75679 Paris Cedex 14, France
| | - A Cariou
- Medical Intensive Care Unit, Cochin Hospital, APHP, Université Paris Descartes, 27, rue du Faubourg Saint Jacques, 75679 Paris Cedex 14, France
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23
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Coppo P, Wolf M, Veyradier A, Bussel A, Malot S, Millot GA, Daubin C, Bordessoule D, Pène F, Mira JP, Heshmati F, Maury E, Guidet B, Boulanger E, Galicier L, Parquet N, Vernant JP, Rondeau E, Azoulay E, Schlemmer B. Prognostic value of inhibitory anti-ADAMTS13 antibodies in adult-acquired thrombotic thrombocytopenic purpura. Br J Haematol 2006; 132:66-74. [PMID: 16371021 DOI: 10.1111/j.1365-2141.2005.05837.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In order to assess the prognostic value of inhibitory anti-ADAMTS13 antibodies in thrombotic thrombocytopenic purpura (TTP), we performed a multicentre prospective study of 33 adult patients with idiopathic acquired TTP. Patients were treated with high-dose plasma infusion and therapeutic plasma exchange. Patients without (group 1, n = 12) and with (group 2, n = 21) detectable inhibitory anti-ADAMTS13 antibodies were compared for clinical presentation, treatment and outcome. Both groups were comparable for clinical presentation. All patients in group 1 achieved a sustained complete remission within a median of 7 d [95% confidence interval (CI), 4-18], which required a median plasma volume of 235 ml/kg (range, 131-1251). In group 2, 17 patients achieved a durable complete remission within a median of 23 d (95% CI, 11-32) (P = 0.001). Median plasma volume was 718 ml/kg (range, 219-3107) (P = 0.02). In group 2, there was a trend for more episodes of flare-up than in group 1 (13 vs. 3, respectively, P = 0.07). Four patients, all from group 2, died (P = not significant). The relapse rate was comparable between both groups. We suggest that TTP with detectable inhibitory anti-ADAMTS13 antibodies displays a worse prognosis, relative to a delayed platelet count recovery, a higher plasma volume requirement to achieve complete remission, and a trend for more frequent episodes of flare-up.
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Affiliation(s)
- P Coppo
- Service d'Hématologie et de Thérapie Cellulaire, Faculté de Médecine Paris VI, Hôpital Saint-Antoine, Paris.
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24
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Mira JP, Charpentier J. [Can genetics guide or modify the management of severe sepsis?]. Ann Fr Anesth Reanim 2003; 22 Spec No 1:48-52. [PMID: 15359945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Affiliation(s)
- J P Mira
- Service de réanimation médicale, CHU Cochin Port-Royal, 27, rue du Faubourg-Saint-Jacques, 75679 Paris cedex 14, France
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25
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Abstract
BACKGROUND Septic shock remains a significant health concern worldwide, and despite progress in understanding the physiological and molecular basis of septic shock, the high mortality rate of patients with septic shock remains unchanged. We recently identified a common polymorphism in toll-like receptor 4 (TLR4) that is associated with hyporesponsiveness to inhaled endotoxin or lipopolysaccharide in humans. METHODS Since TLR4 is a major receptor for lipopolysaccharide in mammals and gram-negative bacteria are the prevalent pathogen associated with septic shock, we investigated whether these specific TLR4 alleles are associated with a predisposition to a more severe disease outcome for patients with septic shock. We genotyped 91 patients with septic shock as well as 73 healthy blood donor controls for the presence of the TLR4 Asp299Gly and TLR4 Thr399Ile mutations. RESULTS We found the TLR4 Asp299Gly allele exclusively in patients with septic shock (P =.05). Furthermore, patients with septic shock with the TLR4 Asp299Gly/Thr399Ile alleles had a higher prevalence of gram-negative infections. CONCLUSION Mutations in the TLR4 receptor may predispose people to develop septic shock with gram-negative microorganisms.
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Affiliation(s)
- Eva Lorenz
- Pulmonary and Critical Care Medicine, Duke University Medical Center, Research Drive, Room 275 MSRB, DUMC Box 2629, Durham, NC 27710, USA.
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Abstract
Explosion of knowledge both in human genomics and in host inflammatory response explains the increasing interest in infectious disease genetics over the last 5 years. However, twin and adoptee studies have suggested more than 15 years ago, that host genetic factors are major determinants of susceptibility to infectious diseases in humans. Recently, candidate gene studies (association studies) and human genomewide analysis have been used to identify infectious diseases susceptibility and resistance genes. Rarely, a single gene defect has been directly related to devastating consequences such as interferon-gamma receptor mutations leading to fatal infections with ubiquitous mycobacteria. For clinical practice, gene polymorphisms of specific host immune defence elements appear to be of major importance. These genetic variants, which modify the regulation or function of the mediators, have been associated with susceptibility and/or outcome of severe sepsis and septic shock. All steps of the host response to bacteria may be affected by genetic factors. For example, Fc gamma receptor, Toll like receptor or mannose binding protein mutations have been shown to modify the detection of pathogens leading to pneumococcal severe infections, Gram-negative bacteria septic shock, and meningococcal disease, respectively. Polymorphisms of cytokine genes (TNF-alpha, TNF-beta, IL-1-ra) have been reported to influence the level of secreted mediators and to unbalance the inflammatory cascade. Coagulation response to sepsis may also be affected by gene variants such as the plaminogen activator inhibitor 1 (PAI-1) common functional polymorphism which increases the risk of death from meningococcal infection or severe trauma. The impact of these findings on the understanding of infectious disease pathogenesis and on the design of future preventive and therapeutic strategies should be considerable.
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Affiliation(s)
- J Charpentier
- Service de réanimation médicale, Institut Cochin de génétique moléculaire, Centre hospitalier universitaire Cochin Saint-Vincent-de-Paul, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
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27
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Mercier JC, Bingen E, Schlegel N, Elion J, Casanova JL, Mira JP, Beaufils F. [Meningococcal purpura fulminans: untoward result of genetic polymorphism?]. Arch Pediatr 2001; 8:843-52. [PMID: 11524916 DOI: 10.1016/s0929-693x(01)00529-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Despite significant progress in intensive care medicine, the mortality of septic shock has not changed in recent years. Early recognition of subtle signs in favor of meningococcal sepsis, early antibiotic treatment, and aggressive hemodynamic support remains the cornerstone of therapy of severe meningococcal shock in children. Recent work has emphasized the role of genetic polymorphisms in various systems to explain the most severe cases: anti-inflammatory cytokine profile IL-10/TNF-alpha, elevated levels of plasminogen activator inhibitor type-1, variants of the gene for mannose-binding lectin complement pathway. This may explain the disillusionment of pediatric intensivists, and the general failure of immunotherapy for sepsis. Reasonable hope lies upon new meningococcal vaccines.
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Affiliation(s)
- J C Mercier
- Service de pédiatrie-réanimation, hôpital Robert-Debré, 48, boulevard Sérurier, 75019 Paris, France.
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Redl HR, Aderem A, Beutler BA, Calandra T, Mira JP, Ulevitch R. Clinical expert round table discussion (session 1) at the Margaux Conference on Critical Illness: innate immunity: host recognition of and sensitivity to bacterial components. Crit Care Med 2001; 29:S19-20. [PMID: 11445729 DOI: 10.1097/00003246-200107001-00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- H R Redl
- Technical University Vienna, Institute for Technical Microscopy, Austria
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29
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Veinstein A, Wernet A, Mira JP. [Septic shock]. Rev Prat 2001; 51:596-602. [PMID: 11345859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
Septic shock is the most severe systemic inflammatory response to infection. Despite recent progress in prevention and critical care therapy, this syndrome is the most common cause of death in intensive care units. Major advances have been realized recently in the understanding of septic shock. Cellular receptors involved in bacterial recognition have been identified as Toll-like receptors. After bacterial challenge, these receptors become activated and initiate in septic shock patients a biphasic immunological response associated with coagulation disorders. Genetic variability among humans and their predisposition towards pathologic inflammatory responses have also been demonstrated. These current views on the pathophysiological aspects of septic shock open new therapeutic perspectives which should change the prognosis of this syndrome.
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Affiliation(s)
- A Veinstein
- Service de réanimation médicale Groupe hospitalier Cochin-Saint-Vincent-de-Paul 75679 Paris
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30
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Arbibe L, Mira JP, Teusch N, Kline L, Guha M, Mackman N, Godowski PJ, Ulevitch RJ, Knaus UG. Toll-like receptor 2-mediated NF-kappa B activation requires a Rac1-dependent pathway. Nat Immunol 2000; 1:533-40. [PMID: 11101877 DOI: 10.1038/82797] [Citation(s) in RCA: 529] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Mammalian Toll-like receptors (TLRs) are expressed on innate immune cells and respond to the membrane components of Gram-positive or Gram-negative bacteria. When activated, they convey signals to transcription factors that orchestrate the inflammatory response. However, the intracellular signaling events following TLR activation are largely unknown. Here we show that TLR2 stimulation by Staphylococcus aureus induces a fast and transient activation of the Rho GTPases Rac1 and Cdc42 in the human monocytic cell line THP-1 and in 293 cells expressing TLR2. Dominant-negative Rac1N17, but not dominant-negative Cdc42N17, block nuclear factor-kappa B (NF-kappa B) transactivation. S. aureus stimulation causes the recruitment of active Rac1 and phosphatidylinositol-3 kinase (PI3K) to the TLR2 cytosolic domain. Tyrosine phosphorylation of TLR2 is required for assembly of a multiprotein complex that is necessary for subsequent NF-kappa B transcriptional activity. A signaling cascade composed of Rac1, PI3K and Akt targets nuclear p65 transactivation independently of I kappa B alpha degradation. Thus Rac1 controls a second, I kappa B-independent, pathway to NF-kappa B activation and is essential in innate immune cell signaling via TLR2.
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Affiliation(s)
- L Arbibe
- Department of Immunology, Scripps Research Institute, La Jolla, CA 92037, USA
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31
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Lorenz E, Mira JP, Cornish KL, Arbour NC, Schwartz DA. A novel polymorphism in the toll-like receptor 2 gene and its potential association with staphylococcal infection. Infect Immun 2000; 68:6398-401. [PMID: 11035751 PMCID: PMC97725 DOI: 10.1128/iai.68.11.6398-6401.2000] [Citation(s) in RCA: 463] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The toll-like receptor 2 (TLR2) has gained importance as a major mammalian receptor for lipoproteins derived from the cell wall of a variety of bacteria, such as Borrelia burgdorferi, Treponema pallidum, and Mycoplasma fermentans. We were interested in identifying mutations in the TLR2 gene that might prove to be associated with altered susceptibility to septic shock. We performed a mutation screen of the TLR2 gene using single-stranded conformational polymorphism in 110 normal, healthy study subjects and detected an Arg753Gln mutation in three individuals. No other missense mutations were detected in the TLR2 open reading frame. Functional studies demonstrate that the Arg753Gln polymorphism, in comparison to the wild-type TLR2 gene, is significantly less responsive to bacterial peptides derived from B. burgdorferi and T. pallidum. In a septic shock population, the Arg753Gln TLR2 polymorphism occurred in 2 out of 91 septic patients. More importantly, both of the subjects with the TLR2 Arg753Gln polymorphism had staphylococcal infections. These findings suggest that a mutation in the TLR2 gene may predispose individuals to life-threatening bacterial infections.
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Affiliation(s)
- E Lorenz
- Department of Medicine, The University of Iowa, Iowa City, USA
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32
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Mira JP, Benard V, Groffen J, Sanders LC, Knaus UG. Endogenous, hyperactive Rac3 controls proliferation of breast cancer cells by a p21-activated kinase-dependent pathway. Proc Natl Acad Sci U S A 2000; 97:185-9. [PMID: 10618392 PMCID: PMC26637 DOI: 10.1073/pnas.97.1.185] [Citation(s) in RCA: 177] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/1999] [Accepted: 11/12/1999] [Indexed: 11/18/2022] Open
Abstract
Uncontrolled cell proliferation is a major feature of cancer. Experimental cellular models have implicated some members of the Rho GTPase family in this process. However, direct evidence for active Rho GTPases in tumors or cancer cell lines has never been provided. In this paper, we show that endogenous, hyperactive Rac3 is present in highly proliferative human breast cancer-derived cell lines and tumor tissues. Rac3 activity results from both its distinct subcellular localization at the membrane and altered regulatory factors affecting the guanine nucleotide state of Rac3. Associated with active Rac3 was deregulated, persistent kinase activity of two isoforms of the Rac effector p21-activated kinase (Pak) and of c-Jun N-terminal kinase (JNK). Introducing dominant-negative Rac3 and Pak1 fragments into a breast cancer cell line revealed that active Rac3 drives Pak and JNK kinase activities by two separate pathways. Only the Rac3-Pak pathway was critical for DNA synthesis, independently of JNK. These findings identify Rac3 as a consistently active Rho GTPase in human cancer cells and suggest an important role for Rac3 and Pak in tumor growth.
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Affiliation(s)
- J P Mira
- Department of Immunology, The Scripps Research Institute, La Jolla, CA 92037, USA
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33
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Mira JP, Cariou A, Grall F, Delclaux C, Losser MR, Heshmati F, Cheval C, Monchi M, Teboul JL, Riché F, Leleu G, Arbibe L, Mignon A, Delpech M, Dhainaut JF. Association of TNF2, a TNF-alpha promoter polymorphism, with septic shock susceptibility and mortality: a multicenter study. JAMA 1999; 282:561-8. [PMID: 10450718 DOI: 10.1001/jama.282.6.561] [Citation(s) in RCA: 508] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
CONTEXT Tumor necrosis factor alpha (TNF-alpha) is believed to be a cytokine central to pathogenesis of septic shock. TNF2, a polymorphism within the TNF-alpha gene promoter, has been associated with enhanced TNF-alpha production and negative outcome in some severe infections. OBJECTIVES To investigate the frequency of the TNF2 allele in patients with septic shock and to determine whether the allele is associated with the occurrence and outcome of septic shock. DESIGN Multicenter case-control study conducted from March 1996 to June 1997. SETTING Seven medical intensive care units in university hospitals. SUBJECTS Eighty-nine patients with septic shock and 87 healthy unrelated blood donors. MAIN OUTCOME MEASURES Frequency of the TNF2 allele among patients with septic shock and among those who died and the level of corresponding TNF-alpha concentrations. RESULTS Mortality among patients with septic shock was 54%, consistent with the predicted mortality from the Simplified Acute Physiologic Score (SAPS II) value. The polymorphism frequencies of the controls and the patients with septic shock differed only at the TNF2 allele (39% vs 18% in the septic shock and control groups, respectively, P =.002). Among the septic shock patients, TNF2 polymorphism frequency was significantly greater among those who had died (52% vs 24% in the survival group, P =.008). Concentrations of TNF-alpha were higher in 68% and 52% with the TNF2 and TNF1 polymorphisms, respectively, but their median values (48 pg/mL vs 29 pg/mL) were not statistically different (P = .31). After controlling for age and the probability of death, derived by the SAPS II score, multiple logistic regression analysis showed that, for the same rank of SAPS II value, patients with the TNF2 allele had a 3.7-fold risk of death (95% confidence interval, 1.37-10.24). CONCLUSION The TNF2 allele is strongly associated with susceptibility to septic shock and death due to septic shock.
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Affiliation(s)
- J P Mira
- Intensive Care Unit, Cochin Port-Royal University Hospital, Paris, France
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Dhainaut JF, Tenaillon A, Hemmer M, Damas P, Le Tulzo Y, Radermacher P, Schaller MD, Sollet JP, Wolff M, Holzapfel L, Zeni F, Vedrinne JM, de Vathaire F, Gourlay ML, Guinot P, Mira JP. Confirmatory platelet-activating factor receptor antagonist trial in patients with severe gram-negative bacterial sepsis: a phase III, randomized, double-blind, placebo-controlled, multicenter trial. BN 52021 Sepsis Investigator Group. Crit Care Med 1998; 26:1963-71. [PMID: 9875905 DOI: 10.1097/00003246-199812000-00021] [Citation(s) in RCA: 125] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the efficacy and safety of using natural platelet-activating factor receptor antagonist (PAFra), BN 52021, to treat patients with severe Gram-negative bacterial sepsis. DESIGN A prospective, randomized, double-blind, placebo-controlled, multicenter clinical trial. SETTING Fifty-nine academic medical center intensive care units in Europe. PATIENTS Six hundred nine patients with severe sepsis, suspected to be related to Gram-negative bacterial infection, who received PAFra or placebo. INTERVENTIONS Patients were randomized to receive either a dose of PAFra (120 mg iv) every 12 hrs over a 4-day period or placebo over a 4-day period. MEASUREMENTS AND MAIN RESULTS The patients were well matched at study entry for severity of illness and for risk factors known to influence the outcome of sepsis. Among all randomized patients, the 28-day, all-cause mortality rate was 49% (152/308) in the placebo group, and 47% (140/300) in the PAFra group (p=.50). When analyzed on the basis of the previously defined target population, the 28-day, all-cause mortality rate was 50% (115/232) in the placebo group and 44% (94/212) in the PAFra group, yielding a 12% reduction in mortality rate (p=.29). In patients with documented infection involving other organisms, there was no difference between treated and placebo groups. When the outcomes of organ dysfunctions were examined in the overall population and in the documented Gram-negative bacterial infection population, the number of patients who resolved hepatic dysfunction tended to be higher in the treated group than in the placebo group (p=.06). The number of adverse events reported were not different between the two groups. CONCLUSIONS A 4-day administration of the studied PAFra (BN 52021) failed to demonstrate a statistically significant reduction in the mortality rate of patients with severe sepsis suspected to be related to Gram-negative bacterial infection. If PAFra treatment has any therapeutic activity in severe Gram-negative bacterial sepsis, the incremental benefits are small and will be difficult to demonstrate in a patient population as defined by this clinical trial.
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Affiliation(s)
- J F Dhainaut
- Medical Intensive Care Unit of Cochin Port-Royal University Hospital, Paris, France
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Lukowski S, Mira JP, Zachowski A, Geny B. Fodrin inhibits phospholipases A2, C, and D by decreasing polyphosphoinositide cell content. Biochem Biophys Res Commun 1998; 248:278-84. [PMID: 9675127 DOI: 10.1006/bbrc.1998.8942] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Brain fodrin inhibited in a dose dependent manner the GTPgammaS-stimulated cytosolic PLA2 (cPLA2), PLC, and PLD activities in differentiated HL-60 cells permeabilized with streptolysin O. cPLA2 and PLD were inhibited by the same concentrations of fodrin (IC50=1.5-2 nM) but PLC was inhibited by lower concentrations (IC50=0.3 nM). Moreover, the rates of inhibition were different between the phospholipases. Spectrin, which shares 50% homology with fodrin, had similar effects on the three phospholipases. However, using cytosol-depleted cells or recombinant PLD1, we showed that fodrin was not a direct inhibitor. Studying the potential mechanisms of these inhibitions, we demonstrated that a major decrease in membrane phosphatidylinositol 4-monophosphate (PtdIns(4)P) and phosphatidylinositol 4,5-bisphosphate (PtdIns(4,5)P2) amounts was induced by fodrin. Exogenous PtdIns(4,5)P2 partly reversed fodrin inhibition of GTPgammaS-stimulated phospholipase C activity. Hence, inhibition of PLC, cPLA2, and PLD activities observed with fodrin could be related to the decrease of PtdIns(4,5)P2, substrate of PLC, a cofactor of PLD and an enhancer of cPLA2 activity.
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Affiliation(s)
- S Lukowski
- Unité INSERM 332, ICGM, 22 rue Méchain, Paris, 75014, Paris, France
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Dubois T, Mira JP, Feliers D, Solito E, Russo-Marie F, Oudinet JP. Annexin V inhibits protein kinase C activity via a mechanism of phospholipid sequestration. Biochem J 1998; 330 ( Pt 3):1277-82. [PMID: 9494097 PMCID: PMC1219273 DOI: 10.1042/bj3301277] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In this study, we assessed the role of annexin V, a Ca2+-dependent phospholipid-binding protein, as a regulator of protein kinase C (PKC) and characterized its mechanism of inhibition. Several mutants obtained by oligonucleotide site-directed mutagenesis were tested in vitro on PKC activity in cytosolic fractions from Jurkat cells and on purified PKCalpha. Annexin V inhibited phosphorylation of annexin II by endogenous PKC and phosphorylation of myelin basic protein by PKCalpha. In both systems, the use of single Ca2+-binding-site mutants of annexin V led to a partial reversal of inhibition, and the Ca2+-binding site located in the first domain of annexin V was found to have the most important role. An increase in the number of mutated Ca2+-binding sites led to a greater loss of inhibition. These results corroborated those showing the progressive loss of binding of these mutants to phospholipid liposomes. In conclusion, we show that PKC inhibition by annexin V is the consequence of a mechanism involving phospholipid sequestration by annexin V, and that the Ca2+-binding site located in domain 1 of annexin V plays a predominant role in this process. In addition, we show that the R122AIK site, which may act analogously to a PKC-inhibitory pseudosubstrate site, is not involved in PKC inhibition, and that a peptide corresponding to the C-terminal tail of annexin V inhibits PKC activity but to a lesser extent than annexin V itself.
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Affiliation(s)
- T Dubois
- INSERM U332, Laboratoire de Signalisation, Inflammation et Transformation Cellulaire, ICGM, 22, Rue Mechain, 75014 Paris, France
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Mira JP, Dubois T, Oudinet JP, Lukowski S, Russo-Marie F, Geny B. Inhibition of cytosolic phospholipase A2 by annexin V in differentiated permeabilized HL-60 cells. Evidence of crucial importance of domain I type II Ca2+-binding site in the mechanism of inhibition. J Biol Chem 1997; 272:10474-82. [PMID: 9099690 DOI: 10.1074/jbc.272.16.10474] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Annexin V belongs to a family of proteins that interact with phospholipids in a Ca2+-dependent manner. This protein has been demonstrated to have anti-phospholipase A2 activity. However, this effect has never yet been reported with the 85-kDa cytosolic PLA2 (cPLA2). We studied, in a model of differentiated and streptolysin O-permeabilized HL-60 cells, the effect of annexin V on cPLA2 activity after stimulation by calcium, GTPgammaS (guanosine 5'-O-(3-thiotriphosphate)), formyl-Met-Leu-Phe, or phorbol 12-myristate 13-acetate. Both recombinant and human placental purified annexin V inhibit cPLA2 activity whatever the stimulus used. The decrease of arachidonic acid release is of 40 and 50%, respectively, at [Ca2+] of 3 and 10 microM. The mechanism of inhibition was also analyzed. cPLA2 requires calcium and protein kinase C (PKC) or mitogen-activated protein kinase phosphorylation for its activation. As annexin V was shown to be an endogenous inhibitor of PKC, PKC-stimulated cPLA2 activity was analyzed. Using GF109203x, a specific PKC inhibitor, we demonstrated that this pathway is of minor importance in our model. cPLA2 inhibition by annexin V is not linked to PKC inhibition. To test the hypothesis of phospholipid depletion, mutants of annexin V were constructed using mutagenesis directed to Ca2+ site. We demonstrate that the Ca2+ site located in domain I is necessary for the inhibitory effect of annexin V on cPLA2 activity. The site in domain IV is also involved but with less efficiency. In contrast, mutations in site II and III do not modify this effect. Moreover, annexin V mutated on all sites does not inhibit cPLA2. Thus, we propose a predominant role of module (I/IV) in the biological action of annexin V, which, in physiological conditions, may control cPLA2 activity by depletion of the phospholipid substrate.
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Affiliation(s)
- J P Mira
- Unité 332, Institut Cochin de Génétique Moleculaire, INSERM, 22 rue Mechain, 75014 Paris, France
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Abstract
Annexins and protein kinases C belong to two distinct families of ubiquitous cytoplasmic proteins involved in signal transduction. All annexins share the property of binding calcium and phospholipids in the presence of calcium. Protein kinases C belong to three distinct groups of kinases: cPKCs (conventional PKCs) depend on calcium, diacylglycerol and negatively charged phospholipids for their activity, nPKCs (novel PKCs) depend on diacylglycerol and negatively charged phospholipids and aPKCs (atypical PKCs) only require negatively charged phospholipids. Almost all annexins are both in vitro and in vivo substrates for PKCs except annexin V. All annexins have a putative binding site for PKCs but only annexin V would possess a potential pseudo-substrate site. We propose that annexin V modulates the activity of some cPKCs on their substrates which may be the other annexins.
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Affiliation(s)
- T Dubois
- INSERM U 332, Institut Cochin de Génétique Moléculaire (ICGM), Paris, France
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Lukowski S, Lecomte MC, Mira JP, Marin P, Gautero H, Russo-Marie F, Geny B. Inhibition of phospholipase D activity by fodrin. An active role for the cytoskeleton. J Biol Chem 1996; 271:24164-71. [PMID: 8798657 DOI: 10.1074/jbc.271.39.24164] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Phospholipase D (PLD) is a major enzyme implicated in important cellular processes such as secretion and proliferation. The knowledge of its regulation is essential to understand the control of these phenomena. Several proteins activating PLD have been described in the last years. In this report, we chromatographed bovine brain cytosolic proteins to identify fodrin, the non-erythroid spectrin, as the first described inhibitor of PLD. A cytosolic fraction with an inhibitory effect on PLD activity loses its capacity after immunoprecipitation of fodrin. Moreover, at 1 nM, purified fodrin blocks fully and quickly PLD activity, whatever the stimuli used. In contrast, fodrin has no effect on adenylate cyclase activity. Fodrin-analogous proteins like dimeric or tetrameric erythroid spectrin have the same inhibitory effect on PLD, at higher concentrations. Other cytoskeletal proteins, actin and vimentin, are inefficient on PLD inhibition. The mechanisms implicated in PLD modulation such as post-translational modifications of fodrin and the role of small G-proteins on the cytoskeleton regulation are discussed. In conclusion, this study reveals that fodrin is involved in the control of PLD activity, suggesting that the cytoskeleton could have an active role in control of secretion and proliferation.
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Brunet F, Jeanbourquin D, Monchi M, Mira JP, Fierobe L, Armaganidis A, Renaud B, Belghith M, Nouira S, Dhainaut JF. Should mechanical ventilation be optimized to blood gases, lung mechanics, or thoracic CT scan? Am J Respir Crit Care Med 1995; 152:524-30. [PMID: 7633702 DOI: 10.1164/ajrccm.152.2.7633702] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
This study was aimed at providing data for optimization of mechanical ventilation in patients with acute respiratory distress syndrome (ARDS). The effects of ventilation with positive end-expiratory pressure (PEEP) titrated to blood gases were studied by thoracic computed tomographic (CT) scans and lung mechanics measurements in eight patients. CT density histograms at end-expiration were used to investigate the effects of PEEP on three differently aerated zones. Static pressure-volume (P-V) curves were used to determine the deflection point above which baro-volotrauma (a combination of barotrauma and volotrauma) may occur. Peak pressures, plateau pressures, and lung volumes measured by Respitrace were compared with the deflection point. CT scan showed that PEEP increased "normally aerated" areas, decreased "nonaerated" areas, and did not change "poorly aerated" zones. No correlations were found between CT scan and either PaO2 or mechanical data. Pressure at the deflection point was lower than the usually recommended 35 to 40 cm H2O for peak pressure in four patients (range, 28 to 32 cm H2O). With regard to plateau pressures, only one patient was ventilated above the deflection point. However, monitoring of volumes showed that these four patients had an end-inspiratory volume above this point. We conclude that mechanical ventilation may be initially adjusted on the basis of blood gas values and then optimized on the basis of lung mechanics to limit the risk of baro-volotrauma.
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Affiliation(s)
- F Brunet
- Intensive Care Unit, Cochin-Port-Royal University-Hospital, Paris, France
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Fierobe L, Brunet F, Dhainaut JF, Monchi M, Belghith M, Mira JP, Dall'ava-Santucci J, Dinh-Xuan AT. Effect of inhaled nitric oxide on right ventricular function in adult respiratory distress syndrome. Am J Respir Crit Care Med 1995; 151:1414-9. [PMID: 7735594 DOI: 10.1164/ajrccm.151.5.7735594] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
To determine whether inhaled nitric oxide (NO) affects pulmonary circulation, thereby improving right ventricular (RV) function in adult respiratory distress syndrome (ARDS), we studied 13 patients with both a lung injury severity score of 2.5 or more and a mean pulmonary artery pressure higher than 30 mm Hg. RV function was assessed by a thermodilution technique using a pulmonary artery catheter equipped with a rapid response thermistor before and 15 min after initiation of inhalation of NO (5 ppm). At baseline, stroke volumes were in a normal range (46 +/- 14 ml/m2), with a RV dilation (end-diastolic volume = 142 +/- 36 ml/m2). Inhaled NO was followed by an improvement in arterial oxygenation (PaO2/FIO2 = 103 +/- 47 versus 142 +/- 63, p < 0.05) and a drop in pulmonary artery pressure (36.1 +/- 4.5 versus 31.3 +/- 6.1 mm Hg, p < 0.01); stroke volumes and heart rates did not change. The resulting fall in pulmonary vascular resistance (211 +/- 43 versus 180 +/- 59 dyn-s/cm5, p < 0.05) was associated with an increase in RV, ejection fractions (32 +/- 5 versus 36 +/- 6%, p < 0.05), a trend toward decreased RV end-systolic (96 +/- 25 versus 85 +/- 19 ml/m2, NS) and end-diastolic (142 +/- 36 versus 131 +/- 27 ml/m2, NS) volumes, and a decrease in right atrial pressures (10.9 +/- 2.9 versus 9.6 +/- 3.2 mm Hg, p < 0.05). No relationship was seen between the improvement in arterial oxygenation and the decrease in pulmonary vascular resistance.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- L Fierobe
- Department of Medical Intensive Care Unit, Cochin Hospital, Cochin-Port-Royal Medical School, René Descartes University, Paris, France
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Abstract
Tracheal gas insufflation (TGI) of pure oxygen combined with mechanical ventilation decreases dead space and increases CO2 clearance. In the present study, TGI was used in six patients with ARDS who met extracorporeal membrane oxygenation criteria and who were severely hypoxemic and hypercapnic despite optimal pressure-controlled ventilation. This open clinical study aimed to investigate the effects of 4 L/min continuous flow of oxygen given via an intratracheal catheter. PaCO2 decreased from 108 +/- 32 to 84 +/- 26 mm Hg (p < 0.05), and no significant change in PaO2 (68 +/- 18 vs 96 +/- 43, p = 0.06). There was no change in airway pressures and hemodynamic variables. A slight increase in end-expiratory and end-inspiratory volumes with TGI possibly occurred, as seen on tracings from respiratory inductive plethysmography (Respitrace). We conclude that TGI improves tolerance of limited pressure ventilation by removing CO2, but it may induce changes in lung volumes that are not detected by ventilator measurements.
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Affiliation(s)
- M Belghith
- Intensive Care Unit, Cochin-University Hospital, Paris, France
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Brunet F, Mira JP, Dhainaut JF, Dall'ava-Santucci J. Efficacy of low-frequency positive-pressure ventilation-extracorporeal CO2 removal. Am J Respir Crit Care Med 1995; 151:1269-70. [PMID: 7697266 DOI: 10.1164/ajrccm/151.4.1269-a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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Brunet F, Mira JP, Dhainaut JF, Dall'ava-Santucci J. Efficacy of low-frequency positive-pressure ventilation-extracorporeal CO2 removal. Am J Respir Crit Care Med 1995. [DOI: 10.1164/ajrccm.151.4.7697266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Mira JP, Brunet F, Belghith M, Soubrane O, Termignon JL, Renaud B, Hamy I, Monchi M, Deslande E, Fierobe L. Reduction of ventilator settings allowed by intravenous oxygenator (IVOX) in ARDS patients. Intensive Care Med 1995; 21:11-7. [PMID: 7560467 DOI: 10.1007/bf02425148] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To evaluate the possibility of reducing ventilator settings to "safe" levels by extrapulmonary gas exchange with IVOX in ARDS patients. DESIGN Uncontrolled open clinical study. SETTING Medical Intensive Care Unit of a University Hospital. PATIENTS 6 patients with ARDS who entered into IVOX phase II clinical trials. INTERVENTIONS The end-point of this study was to reduce ventilator settings from the initial values, recorded on the day of inclusion, to the following: peak inspiratory pressure < 40 cmH2O, mean airway pressure < 25 cmH2O and tidal volume < 10 ml/kg. Trials to achieve this goal were made on volume-controlled ventilation within the 24 h before and after IVOX insertion. Comparison of the results achieved during these trials used Wilcoxon test. RESULTS Before IVOX implantation reduction of ventilator settings was not possible in the 6 patients, despite a non-significant increase in PaO2/FIO2 was achieved. IVOX permitted significant decrease in PaCO2 (from 60.5 +/- 15 to 52 +/- 11 mmHg; p = 0.02) before any modification of the ventilatory mode. After IVOX insertion, a significant decrease of the ventilator settings was performed: peak and mean airway pressures dropped from 44 +/- 10 to 36.8 +/- 6.7; p = 0.02 and from 26.3 +/- 5.6 to 22.5 +/- 3.9 cmH2O; p = 0.02, respectively. Concommitantly, PaCO2 remained unchanged and PaO2/FIO2 increased significantly from 93 +/- 28 to 117 +/- 52; p = 0.04. The interruption of oxygen flow on IVOX was associated with a slight decrease of the oxygen variables. Tolerance of IVOX was satisfactory. However, a significant decrease both in cardiac index and in pulmonary wedge pressures (from 4.5 +/- 1.2 to 3.4 +/- 9; p = 0.03 and from 16 +/- 5 to 11 +/- 2; p = 0.04, respectively) was observed. CONCLUSION Gas exchange achieved by IVOX allowed reduction of ventilator settings in 6 ARDS patients in whom previous attempts have failed. CO2 removal by the device, may explain these results. Efficacy of IVOX on arterial oxygenation was uncertain.
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Affiliation(s)
- J P Mira
- Service de Réanimation Médicale, Hôpital Cochin, Paris, France
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Pochard F, Lanore JJ, Bellivier F, Ferrand I, Mira JP, Belghith M, Brunet F, Dhainaut JF. Subjective psychological status of severely ill patients discharged from mechanical ventilation. Clin Intensive Care 1994; 6:57-61. [PMID: 10150800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
OBJECTIVE To evaluate psychological status in consecutive survivors of ICU who needed mechanical ventilation (MV). DESIGN Prospective study. SETTING Twenty-four bed intensive care unit. PATIENTS Fifty-four mechanically ventilated patients were considered for the study; 43 patients were included, but 11 refused or were unable to fill in the form. INTERVENTIONS A 32-question form was filled out by the patients 48-96 hours after weaning from mechanical ventilation. MEASUREMENTS AND MAIN RESULTS The mean characteristics of the patients were: age 51.6 years, simplified acute physiologic score (SAPS) 14, organ system failure (OSF) 1.57, OMEGA score 277, length of stay 29 days, length of mechanical ventilation 14 days. Thirty-three required sedation, 30 analgesia, 20 paralysis. The results were as follows: Pain: 13 suffered intolerable pain with a mean intensity of pain during care of 3.5/10. Comfort: 25 felt an inability to communicate, 18 were bothered by noise and 15 by light, while nine feared to be abandoned by staff. Sleep disorders: 28 remember dreaming with a personal judgement about these dreams (0 = pleasant, 10 = nightmare) of 7.6/10; 17 noticed increasing sleep disorders during their stay. Anxiety: 22 felt diffuse anxiety disorder and 16 described intense fear of dying at least once. Mood: 38 felt physical depression and 18 intellectual depression. Delirium or confusion: 33 had delirium or a confused state at the time of weaning and nine suffered hallucinations. Nine correctly appreciated their length of stay and 18 knew the date when they were interviewed. CONCLUSIONS These results showed that psychological status is poor in ventilated ICU patients, which should be considered in their care.
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Affiliation(s)
- F Pochard
- Medical Intensive Care Unit, Cochin-Port Royal University Hospital, Paris, France
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Mira JP, Fabre JE, Baigorri F, Coste J, Annat G, Artigas A, Nitenberg G, Dhainaut JF. Lack of oxygen supply dependency in patients with severe sepsis. A study of oxygen delivery increased by military antishock trouser and dobutamine. Chest 1994; 106:1524-31. [PMID: 7956414 DOI: 10.1378/chest.106.5.1524] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND During severe sepsis, the existence of a pathologic oxygen supply dependency remains controversial. STUDY OBJECTIVE To evaluate the relationship between oxygen delivery (DO2) and oxygen consumption (VO2) during severe sepsis and to compare, in this respect, survivors and nonsurvivors and patients with normal or increased concentration of plasma lactate. STUDY DESIGN Cohort analytic study. SETTING Three European ICUs in university hospitals. PATIENTS Seventeen mechanically ventilated patients with severe sepsis (six with high blood lactate levels) studied within the first day of diagnosis. INTERVENTIONS AND MEASUREMENTS Pulmonary elimination of carbon dioxide, or carbon dioxide production (VCO2) and VO2 were measured by indirect calorimetry before and after two interventions designed to increase DO2 (calculated from the Fick equation): inflation of a military antishock trouser (MAST) and infusion of dobutamine. RESULTS During MAST inflation, DO2 increased by 19% in patients with a normal concentration of plasma lactate (p < 0.01), but remained unchanged in patients with high lactate levels. During dobutamine infusion, DO2 increased in both groups by 16% (p < 0.01) and 20% (p < 0.05), respectively. In both groups, we found that the VO2 and VCO2 were not affected by either the MAST or the dobutamine-induced increase in DO2. There was no difference between survivors and nonsurvivors. CONCLUSION There was no evidence of a pathologic oxygen supply dependency in patients with severe sepsis, even in those who had an elevated concentration of plasma lactate and in those who ultimately died. These results do not favor the conclusion that maximizing DO2 is a primary therapeutic objective in such patients.
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Affiliation(s)
- J P Mira
- Intensive Care Unit, Cochin Port-Royal University Hospital, Paris, France
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Brunet F, Mira JP, Cerf C, Belghith M, Soubrane O, Termignon JL, Renaud B, Fierobe L, Hamy I, Monchi M. Permissive hypercapnia and intravascular oxygenator in the treatment of patients with ARDS. Artif Organs 1994; 18:826-32. [PMID: 7864732 DOI: 10.1111/j.1525-1594.1994.tb03331.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
This open clinical study was aimed at testing the hypothesis that an intravascular oxygenator (IVOX) may help to perform permissive hypoventilation in 10 patients with severe ARDS. After initial evaluation, we tried to reduce ventilator settings before and after IVOX implantation. Before IVOX, poor clinical tolerance and worsening oxygenation did not allow for a significant decrease in ventilator settings. With IVOX, peak inspiratory pressure (PIP) was reduced from 47 to 39 cm H2O (p = 0.005) and minute ventilation from 13 +/- 3.5 to 11 +/- 3 L/min. CO2 removal by IVOX allowed a significant decrease in PaCO2 from 66 +/- 15 to 59 +/- 13 mm Hg. Improvement of oxygenation with IVOX was not significant. Furthermore, interruption of oxygen flow through IVOX did not change oxygenation variables. Tolerance of the IVOX device was good, but insertion of the device was followed by a significant decrease in both cardiac index and pulmonary wedge pressure. In conclusion, IVOX improves tolerance of hypoventilation by limiting hypercapnia in ARDS patients. These preliminary results must be confirmed by a randomized controlled study.
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Affiliation(s)
- F Brunet
- Intensive Care Unit, Cochin Hospital, Paris, France
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Dhainaut JF, Tenaillon A, Le Tulzo Y, Schlemmer B, Solet JP, Wolff M, Holzapfel L, Zeni F, Dreyfuss D, Mira JP. Platelet-activating factor receptor antagonist BN 52021 in the treatment of severe sepsis: a randomized, double-blind, placebo-controlled, multicenter clinical trial. BN 52021 Sepsis Study Group. Crit Care Med 1994; 22:1720-8. [PMID: 7956274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To evaluate the safety and efficacy of a natural platelet-activating factor receptor antagonist, BN 52021 (Ginkgolide B), in the treatment of patients with sepsis syndrome. DESIGN Prospective, randomized, placebo-controlled, double-blind, phase III, multicenter clinical trial. SETTING Twenty-one academic medical center intensive care units in France. PATIENTS Two hundred sixty-two patients with sepsis syndrome who received standard supportive care and antimicrobial therapy, in addition to the administration of platelet-activating factor receptor antagonist or placebo. INTERVENTIONS Patients received either a 120-mg dose of platelet-activating factor receptor antagonist intravenously every 12 hrs over a 4-day period or placebo. MAIN OUTCOME MEASUREMENTS All patients were evaluated for 28-day, all-cause mortality. RESULTS The 28-day mortality rate was 51% for the placebo group and 42% for the platelet-activating factor receptor antagonist group (p = .17). However, the efficacy of platelet-activating factor receptor antagonist was significantly greater in patients with Gram-negative sepsis (test for interaction, p = .03). In a separate analysis of patients with and without Gram-negative sepsis, the 28-day mortality rate was 57% for the patients receiving placebo (30 deaths of 53 patients) and 33% for patients receiving platelet-activating factor receptor antagonist (22 deaths of 67 patients; p = .01). Platelet-activating factor receptor antagonist also significantly (p = .01) reduced the mortality rate among patients with Gram-negative sepsis who were in shock at entry into the study (mortality rate was 65% for placebo vs. 37% for platelet-activating factor receptor antagonist) and among patients > 60 yrs of age (mortality rate was 74% for placebo vs. 31% for platelet-activating factor receptor antagonist). A Cox proportional-hazards model identified five independent prognostic factors: a) adequacy of antibiotic therapy; b) severity of illness; c) renal failure; d) hematologic failure; and e) hepatic failure at study entry. When the Gram-negative sepsis population was stratified by age and these five prognostic factors were controlled for, the relative risk of death of the platelet-activating factor receptor antagonist group was 0.61 (0.34 to 1.08, 95% confidence interval; p = .09). This risk corresponds with an adjusted reduction in mortality rate of 39% for patients receiving platelet-activating factor receptor antagonist. No differences in mortality rates were found between the placebo and the platelet-activating factor receptor antagonist groups in the absence of Gram-negative sepsis. There were no differences in adverse events between the placebo and the treated groups. CONCLUSION The studied platelet-activating factor receptor antagonist (BN 52021) seems to be a safe and promising treatment for patients with severe Gram-negative sepsis.
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Affiliation(s)
- J F Dhainaut
- Medical Intensive Care Units, Cochin Port-Royal University Hospital, Paris, France
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