[Fatal course of COVID-19 despite IL-6 receptor blockade in cytokine storm : Perimyocarditis and coagulopathy after administration of tocilizumab]

A 59-year-old male patient was admitted to hospital diagnosed with moderate pneumonia associated with COVID-19. Upfront treatment with hydroxychloroquine and azithromycin was started. Due to a clinical deterioration (ARDS, circulatory shock) and greatly increased inflammation markers 6 days after admission, a cytokine storm was suspected and off-label treatment with the IL‑6 receptor antagonist tocilizumab was initiated. Subsequently there was a dramatic rise of D‑dimers indicating pulmonary intravascular coagulopathy and respiratory insufficiency worsened. After a second dose of tocilizumab was administered severe perimyocarditis with cardiac arrhythmia, hemodynamic instability and ST elevation occurred. Shortly afterwards the patient died due to multiorgan failure. From our experience, exacerbation of COVID-19 following treatment with tocilizumab cannot be ruled out. Randomized controlled studies are necessary to further investigate the efficacy, safety and patient selection criteria for tocilizumab treatment in COVID-19.

Mortality related to anaesthesia in France: analysis of deaths related to airway complications

Death certificates from the French national mortality database for the calendar year 1999 were reviewed to analyse cases in which airway complications had contributed to peri-operative death. Respiratory deaths (and comas) found in a previous national 1978-82 French survey (1:7960; 95% CI 1:12,700 to 1:5400) were compared with the death rate found in the present one: 1:48,200 (95% CI 1:140,000 to 1:27,500). In 1999, deaths associated with failure of the breathing circuit and equipment were no longer encountered and no death was found to be related to undetected hypoxia in the recovery unit. Deaths related to difficult intubation also occurred at a lower rate than in the previous report (1:46,000; 95% CI 1:386,000 to 1:13,000) in 1978-82 vs 1:176,000 (95% CI 1:714,000 to 1:46,000) in 1999, a fourfold reduction. In most cases, there were both inadequate practice and systems failure (inappropriate communication between staff, inadequate supervision, poor organisation). This large French survey shows that deaths associated with respiratory complications during anaesthesia have been strikingly reduced during this 15-year period.

Mortality related to chronic hepatitis B and chronic hepatitis C in France: evidence for the role of HIV coinfection and alcohol consumption

BACKGROUND/AIMS

Mortality related to HCV and HBV infections was estimated in France.

METHODS

A random sample (n=999) of death certificates was obtained from all death certificates listing HBV, HCV, hepatitis, liver disease, possible complication of cirrhosis, bacterial infection, HIV, or transplantation (n=65,000) in France in 2001. Physicians who reported the deaths were sent a questionnaire to identify how many deaths were related to HBV/HCV infection. Completed forms were independently analyzed by a panel of hepatologists. Death rates were estimated according to national population census data.

RESULTS

Estimated annual number of deaths associated with HCV and HBV infection was 3618 and 1507, respectively (6.1 and 2.5 deaths per 100,000 inhabitants, respectively). Estimated number of deaths attributable to HCV or HBV infection was 2646 and 1327, respectively (4.5 and 2.2 deaths per 100,000 inhabitants, respectively). In the HCV infection group, 95 percent had cirrhosis; 33 percent had hepatocellular carcinoma (HCC). In the HBV infection group, 93 percent had cirrhosis; 35 percent had HCC. Eleven percent of deaths occurred in patients with HIV coinfection. Deaths related to HBV or HCV infection occurred at an earlier age in patients with a history of excessive alcohol consumption.

CONCLUSIONS

In France, 4000-5000 deaths related to HCV and HBV infection occurred in 2001. Alcohol consumption and HIV infection were important co-factors. These data emphasize the need for ongoing, efficient public health programs that include screening, management, and counseling for HCV- and HBV-infected individuals.

Survey of anesthesia-related mortality in France

BACKGROUND

This study describes a nationwide survey that estimates the number and characteristics of anesthesia-related deaths for the year 1999.

METHODS

Death certificates from the French national mortality database were selected from the International Classification of Diseases, Ninth Revision codes using a variable sampling fraction. Medical certifiers were sent a questionnaire (response rate, 97%), and the anesthesiologist in charge was offered a peer review (acceptance rate, 97%). Files were reviewed to determine the mechanism of each perioperative death and its relation to anesthesia. Mortality rates were calculated using the number of anesthetic procedures estimated from a national 1996 survey and compared with a previous (1978-1982) nationwide study.

RESULTS

Among the 4,200 certificates analyzed, 256 led to a detailed evaluation. The death rates totally or partially related to anesthesia for 1999 were 0.69 in 100,000 (95% confidence interval, 0.22-1.2 in 100,000) and 4.7 in 100,000 (3.1-6.3 in 100,000), respectively. The death rate increased from 0.4 to 55 in 100,000 for American Society of Anesthesiologists physical status I and IV patients, respectively. Rates increased with increasing age. Although concerns regarding aspiration of gastric contents remain, intraoperative hypotension and anemia associated with postoperative ischemic complications were the associated factors most often encountered. Deviations from standard practice and organizational failure were often found to be associated with death.

CONCLUSION

In comparison with data from a previous nationwide study (1978-1982), the anesthesia-related mortality rate in France seems to be reduced 10-fold in 1999. Much remains to be done to improve compliance of physicians to standard practice and to improve the anesthetic system process.

Excited states mapped by secondary photoemission

We report on angle-resolved photoemission (ARPES) experiments on Cu(110) using Mg K(alpha) radiation. The secondary emission (SE) fine structure of electrons below 50 eV is found to map the empty band structure relevant for absolute band mapping in ARPES. The finding is based on a direct comparison of our experiments with very low-energy electron diffraction data [Phys. Rev. Lett. 81, 4943 (1998)]] recently shown to map the unoccupied states representing the photoemission final-state. This suggests a new theoretical approach to the SE process treating the outgoing electron state as the time-reversed diffraction state.

[Preliminary results from the SFAR-iNSERM inquiry on anaesthesia-related deaths in France: mortality rates have fallen ten-fold over the past two decades]

A National Confidential Inquiry was conducted among death certificators and anaesthetists. A sample of 3700 death certificates from the year 1999 were randomised, after selection of words relating to anaesthesia, surgery, obstetrics, endoscopy, procedural complications, and violent death, with different ratios according to the words and the age; 500 additional certificates relating to deaths in hospital were evaluated to verify the exhaustive nature of the mention of procedures in the certificates. The certificator was sent a simplified form each time the role of the procedure in death could not be excluded (response rate 97%). The anaesthetist was offered a peer review whenever the role of the anaesthetic procedure could not be ruled out (uptake rate 97%). An expert committee analysed the (anonymized) files to determinate the mechanism of the accident and its relationship to anaesthesia. The mortality rates were estimated from the 1996 "Anaesthesia in France" survey. The annual rates of deaths that were totally or partially related to anaesthesia were respectively 7 (CI95%: 2-12) and 47 (31-63) per million. These mortality rates increased with comorbidity, from 4 per million in patients of ASA physical status class 1 to 554 per million in class 4. Similarly, these rates increased with age, from 7 per million in patients less than 45 years old, to 32 in older patients. Most accidents were of ventilatory (38%: airway management: 6%, aspiration pneumonitis: 9%), cardiac (31%: ischaemia: 25%, including anaemia-related), and vascular origin (30%: hemorrhage: 12%, vasodilation by spinal anaesthesia: 6%, anaphylaxis: 3%). The main surgical procedures involved were orthopaedic (50%: hip fracture, haemorrhagic surgery) and digestive (24%: occlusion, peritonitis). INSERM had previously collected data on complications associated with anaesthesia between 1978 and 1982: the annual rates of deaths that were totally or partially related to anaesthesia were respectively 76 and 263 per million. Compared to these previous data, the anaesthesia-related mortality rate fell ten-fold over the last two decades, while the number of anaesthetic procedures at least doubled. In addition, the number of procedures involving old people and patients with poor physical status was multiplied by four. It seems logical to attribute these results to safety and practice guidelines published after the previous inquiry. Progress remains to be made: the present rate of 1/145000 will serve as a basis for systematic analysis of accidents.

Electronic structure of the YH3 phase from angle-resolved photoemission spectroscopy

Yttrium can be loaded with hydrogen up to high concentrations causing dramatic structural and electronic changes of the host lattice. We report on angle-resolved photoemission experiments of the Y trihydride phase. Most importantly, we find the absence of metal d bands at the Fermi level and a set of flat, H-induced bands located at much higher binding energy than predicted, indicating an increased electron affinity at H sites.

Intestinal absorption of amiodarone in man

The jejunal absorption rate of amiodarone and the influence of lipids on it were studied in human volunteers using the intestinal perfusion technique. A nutrient solution (Realmentyl, Sopharga Laboratories, France) with 300 mg of the drug was infused for 120 minutes at the ligament of Treitz. The segment tested was 25 cm long. Two caloric loads of the nutrient solution, 3.3 Kcal/min (solution A) and 1.3 Kcal/min (solution B), A containing total lipid and caloric load 2.5 times higher than B, were administered. Minor interindividual differences in amiodarone absorption rate were observed (20.2 to 31.7%) with solution A. Amiodarone absorption correlated with lipid absorption significantly. Since the maximal plasma concentrations of the drug and the area under the curve (AUC/24 hours) did not correlate with the amount of amiodarone absorbed, the wide fluctuations of amiodarone pharmacokinetics must mainly be due to amiodarone tissue distribution and metabolic pathway.

Effect of different caloric loads in human jejunum on meal-stimulated and nonstimulated biliopancreatic secretion

The effects on biliopancreatic secretion of two caloric loads (1.3 and 3.3 kcal/min of Realmentyl: proteins 18%, lipids 27%, carbohydrates 55%), infused into the jejuna of 10 healthy men, were compared with those of a control solution. In one set of experiments (six subjects) when biliopancreatic secretion was not stimulated before infusion, the rate 1.3 kcal/min resulted in mild stimulation whereas the rate 3.3 kcal/min brought about an inhibition of biliopancreatic secretion. In another set of experiments (six subjects) when biliopancreatic secretion was stimulated by ingestion of an homogenized meal (400 mL, 490 kcal) 1 h before the start of infusion, both loads resulted in strong inhibition of pancreatic secretions, the effect being more pronounced with the high caloric load.

Jejunal and ileal absorption of oxprenolol in man: influence of nutrients and digestive secretions on jejunal absorption and systemic availability

1 Study I evaluated the absorption of oxprenolol in the ileum, compared to jejunum, in healthy volunteers by an intestinal perfusion technique. Around 80 mg of drug were delivered as a saline solution directly in the small bowel. 2 Samples taken 30 cm distally to the site of perfusion showed that 63% of perfused oxprenolol was absorbed in the jejunum and 48% in the ileum; the differences were significant. 3 The plasma concentration-time profiles were similar for the two perfusions. The AUC and Cmax values of free and conjugated oxprenolol for the jejunal perfusion were significantly lower than those of ileum. They showed large but consistent intersubject variations in the two treatments. 4 Study II investigated, using the same technique, the influence of nutrients and digestive secretions on jejunal absorption and systemic availability of this drug. A saline (in treatments A and B) or a nutrient (in treatment C) solution containing oxprenolol was perfused into the jejunum below a balloon either inflated (A) or deflated (B and C). 5 The disappearance rate of oxprenolol from the jejunum was unaffected by endogenous secretions. The mean amount of drug absorbed along a 30-cm jejunal segment accounted for 52 (A) and 57% (B) of the total amount perfused. The intestinal absorption rate was markedly increased in the presence of nutrients (mean amount absorbed 96% for C). 6 The change in the rate of disappearance from the intestine had no effect on the systemic availability of oxprenolol (mean AUC values 8740, 8250 and 8020 nmol l-1 h for A, B and C, respectively) or its elimination from plasma.(ABSTRACT TRUNCATED AT 250 WORDS)

Investigation of drug absorption from the gastrointestinal tract of man. IV. Influence of food and digestive secretions on metoprolol jejunal absorption

The influence of nutrients and digestive secretions on the intestinal absorption and bioavailability of the beta-adrenoceptor antagonist, metoprolol, was investigated in an isolated segment of jejunum using an intestinal perfusion technique. Two solutions containing metoprolol, one with, and one without nutrients, were perfused into the jejunum with an occluding balloon inflated or deflated. Jejunal fluid, blood and urine samples were then collected for drug or metabolite estimation. In the segment studied, metoprolol absorption from the nutrient solution was four times that observed during perfusion of the saline solution. Bile salts did not enhance drug absorption. Both in the presence and absence of nutrients, a linear relationship was observed between the computed cumulative amount of drug absorbed from the gastrointestinal tract and the resulting plasma concentration at each sampling time, indicating that first-pass loss was not saturated. This result was also reflected in the similarity of the AUC:dose ratios, and in the lack of effect of nutrients on the metabolism of the drug.