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Manhaeghe L, Goethals AM, Van Aerde N, Frederiks P, Sinnaeve P, Janssens S, Willems R. Pheochromocytoma leading to Takotsubo and Ogilvie syndrome, a pathophysiological triad. Acta Cardiol 2024; 79:109-113. [PMID: 37823390 DOI: 10.1080/00015385.2023.2268438] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 10/03/2023] [Indexed: 10/13/2023]
Abstract
Takotsubo syndrome (TTS) is a transient left ventricle dysfunction usually caused by a stressful trigger (emotional or physical). We report the case of a 77 year-old female patient who presented with TTS caused by a pheochromocytoma, a catecholamine-producing neuroendocrine tumour. Diagnosis was facilitated by acute kidney injury prompting renal ultrasound, recurrence of TTS and symptoms of episodic palpitations, profuse sweating and labile blood pressure. Furthermore, during her hospitalisation the patient also developed an Ogilvie syndrome, an acute colonic pseudo-obstruction, due to the catecholamine-excess. Treatment consisted of betablocker and angiotensin-converting enzyme inhibitor for TTS, neostigmine for Ogilvie syndrome, in combination with alpha-blocker and surgical removal of the tumour after recuperation of left ventricular function and colonic pseudo-obstruction. To our knowledge, this is the first case report of the pathophysiological triad of pheochromocytoma leading to Takotsubo and Ogilvie syndrome in a single patient.
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Affiliation(s)
- Lynn Manhaeghe
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | | | - Nathalie Van Aerde
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Pascal Frederiks
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Peter Sinnaeve
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven - University of Leuven, Leuven, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven - University of Leuven, Leuven, Belgium
| | - Rik Willems
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven - University of Leuven, Leuven, Belgium
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Téblick A, Van Dyck L, Van Aerde N, Vander Perre S, Pauwels L, Derese I, Debaveye Y, Wouters PJ, Vanhorebeek I, Langouche L, Van den Berghe G. OR26-4 Glucocorticoid Receptor Expression and Signaling During Critical Illness, in Relation to the Duration of Illness and the Systemic Glucocorticoid Availability: A Prospective, Observational, Cross-Sectional Human and a Translational Mouse Study. J Endocr Soc 2022. [DOI: 10.1210/jendso/bvac150.1497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Abstract
Critically ill patients are thought to develop maladaptive glucocorticoid-resistance which convinces many clinicians to administer stress doses of glucocorticoids to overcome this state of glucocorticoid-resistance. However, supportive data arises mainly from whole blood cells. It is currently not known if the observed changes in regulators and markers of glucocorticoid signaling and activity are also present in other cell and tissue types with a role in critical illness. We quantified regulators and markers of glucocorticoid signaling and activity in several cell and tissue types in critically ill humans and animals and in healthy controls. We found that throughout critical illness, glucocorticoid activity appeared suppressed in neutrophils, but upregulated in monocytes and skeletal muscle. Also in vital tissues GRα-signaling was altered in a tissue-specific, largely time-independent manner. Increasing systemic glucocorticoid availability increased glucocorticoid activity in adipose tissue, diaphragm and lung, whereas in immune cells and other tissues regulatory pathways counteracted. These data argue against glucocorticoid-treatable generalized glucocorticoid resistance and rather point towards an adaptive response in each specific cell or tissue type to optimally guide the beneficial actions of glucocorticoids to the tissues that need it while protecting collateral undesirable effects in tissue that are harmed by elevated systemic glucocorticoid availability.
Presentation: Monday, June 13, 2022 11:45 a.m. - 12:00 p.m.
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Téblick A, Van Dyck L, Van Aerde N, Van der Perre S, Pauwels L, Derese I, Debaveye Y, Wouters PJ, Vanhorebeek I, Langouche L, Van den Berghe G. Impact of duration of critical illness and level of systemic glucocorticoid availability on tissue-specific glucocorticoid receptor expression and actions: A prospective, observational, cross-sectional human and two translational mouse studies. EBioMedicine 2022; 80:104057. [PMID: 35584557 PMCID: PMC9117556 DOI: 10.1016/j.ebiom.2022.104057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 02/23/2022] [Revised: 04/19/2022] [Accepted: 04/27/2022] [Indexed: 12/24/2022] Open
Abstract
Background Reduced glucocorticoid-receptor (GR) expression in blood suggested that critically ill patients become glucocorticoid-resistant necessitating stress-doses of glucocorticoids. We hypothesised that critical illness evokes a tissue-specific, time-dependent expression of regulators of GR-action which adaptively guides glucocorticoid action to sites of need. Methods We performed a prospective, observational, cross-sectional human study and two translational mouse studies. In freshly-isolated neutrophils and monocytes and in skeletal muscle and subcutaneous adipose tissue of 137 critically ill patients and 20 healthy controls and in skeletal muscle and adipose tissue as well as in vital tissues (heart, lung, diaphragm, liver, kidney) of 88 septic and 26 healthy mice, we quantified gene expression of cortisone-reductase 11β-HSD1, glucocorticoid-receptor-isoforms GRα and GRβ, GRα-sensitivity-regulating-co-chaperone FKBP51, and GR-action-marker GILZ. Expression profiles were compared in relation to illness-duration and systemic-glucocorticoid-availability. Findings In patients’ neutrophils, GRα and GILZ were substantially suppressed (p≤0·05) throughout intensive care unit (ICU)-stay, while in monocytes low/normal GRα coincided with increased GILZ (p≤0·05). FKBP51 was increased transiently (neutrophils) or always (monocytes,p≤0·05). In patients’ muscle, 11β-HSD1 and GRα were low-normal (p≤0·05) and substantially suppressed in adipose tissue (p≤0·05); FKBP51 and GILZ were increased in skeletal muscle (p≤0·05) but normal in adipose tissue. GRβ was undetectable. Increasing systemic glucocorticoid availability in patients independently associated with further suppressed muscle 11β-HSD1 and GRα, further increased FKBP51 and unaltered GILZ (p≤0·05). In septic mouse heart and lung, 11β-HSD1, FKBP51 and GILZ were always high (p≤0·01). In heart, GRα was suppressed (p≤0·05), while normal or high in lung (all p≤0·05). In diaphragm, 11β-HSD1 was high/normal, GRα low/normal and FKBP51 and GILZ high (p≤0·01). In kidney, 11β-HSD1 transiently increased but decreased thereafter, GRα was normal and FKBP51 and GILZ high (p≤0·01). In liver, 11β-HSD1 was suppressed (p≤0·01), GRα normal and FKBP51 high (p≤0·01) whereas GILZ was transiently decreased but elevated thereafter (p≤0·05). Only in lung and diaphragm, treatment with hydrocortisone further increased GILZ. Interpretation Tissue-specific, time-independent adaptations to critical illness guided GR-action predominantly to vital tissues such as lung, while (partially) protecting against collateral harm in other cells and tissues, such as neutrophils. These findings argue against maladaptive generalised glucocorticoid-resistance necessitating glucocorticoid-treatment. Funding Research-Foundation-Flanders, Methusalem-Program-Flemish-Government, European-Research-Council, European-Respiratory-Society.
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Affiliation(s)
- Arno Téblick
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Lisa Van Dyck
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Nathalie Van Aerde
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Sarah Van der Perre
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Lies Pauwels
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Inge Derese
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Yves Debaveye
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Pieter J Wouters
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Ilse Vanhorebeek
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Lies Langouche
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.
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Van Aerde N, Meersseman P, Debaveye Y, Wilmer A, Casaer MP, Gunst J, Wauters J, Wouters PJ, Goetschalckx K, Gosselink R, Van den Berghe G, Hermans G. Aerobic exercise capacity in long-term survivors of critical illness: secondary analysis of the post-EPaNIC follow-up study. Intensive Care Med 2021; 47:1462-1471. [PMID: 34750648 PMCID: PMC8575347 DOI: 10.1007/s00134-021-06541-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 05/20/2021] [Accepted: 09/15/2021] [Indexed: 11/26/2022]
Abstract
Purpose To evaluate aerobic exercise capacity in 5-year intensive care unit (ICU) survivors and to assess the association between severity of organ failure in ICU and exercise capacity up to 5-year follow-up. Methods Secondary analysis of the EPaNIC follow-up cohort (NCT00512122) including 433 patients screened with cardiopulmonary exercise testing (CPET) between 1 and 5 years following ICU admission. Exercise capacity in 5-year ICU survivors (N = 361) was referenced to a historic sedentary population and further compared to demographically matched controls (N = 49). In 5-year ICU survivors performing a maximal CPET (respiratory exchange ratio > 1.05, N = 313), abnormal exercise capacity was defined as peak oxygen consumption (VO2peak) < 85% of predicted peak oxygen consumption (%predVO2peak), based on the historic sedentary population. Exercise liming factors were identified. To study the association between severity of organ failure, quantified as the maximal Sequential Organ Failure Assessment score during ICU-stay (SOFA-max), and exercise capacity as assessed with VO2peak, a linear mixed model was built, adjusting for predefined confounders and including all follow-up CPET studies. Results Exercise capacity was abnormal in 118/313 (37.7%) 5-year survivors versus 1/48 (2.1%) controls with a maximal CPET, p < 0.001. Aerobic exercise capacity was lower in 5-year survivors than in controls (VO2peak: 24.0 ± 9.7 ml/min/kg versus 31.7 ± 8.4 ml/min/kg, p < 0.001; %predVO2peak: 94% ± 31% versus 123% ± 25%, p < 0.001). Muscular limitation frequently contributed to impaired exercise capacity at 5-year [71/118 (60.2%)]. SOFA-max independently associated with VO2peak throughout follow-up. Conclusions Critical illness survivors often display abnormal aerobic exercise capacity, frequently involving muscular limitation. Severity of organ failure throughout the ICU stay independently associates with these impairments. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06541-9.
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Affiliation(s)
- Nathalie Van Aerde
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Philippe Meersseman
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Yves Debaveye
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Alexander Wilmer
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Michael P Casaer
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Jan Gunst
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Joost Wauters
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Pieter J Wouters
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Kaatje Goetschalckx
- Department of Cardiovascular Sciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Rik Gosselink
- Department of Rehabilitation Sciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Greet Van den Berghe
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Greet Hermans
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
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Metzemaekers M, Cambier S, Blanter M, Vandooren J, de Carvalho AC, Malengier‐Devlies B, Vanderbeke L, Jacobs C, Coenen S, Martens E, Pörtner N, Vanbrabant L, Van Mol P, Van Herck Y, Van Aerde N, Hermans G, Gunst J, Borin A, Toledo N Pereira B, dos SP Gomes AB, Primon Muraro S, Fabiano de Souza G, S Farias A, Proenca‐Modena JL, R Vinolo MA, Marques PE, Wouters C, Wauters E, Struyf S, Matthys P, Opdenakker G, Marques RE, Wauters J, Gouwy M, Proost P. Kinetics of peripheral blood neutrophils in severe coronavirus disease 2019. Clin Transl Immunology 2021; 10:e1271. [PMID: 33968405 PMCID: PMC8082714 DOI: 10.1002/cti2.1271] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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] [Received: 01/07/2021] [Revised: 03/08/2021] [Accepted: 03/08/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Emerging evidence of dysregulation of the myeloid cell compartment urges investigations on neutrophil characteristics in coronavirus disease 2019 (COVID-19). We isolated neutrophils from the blood of COVID-19 patients receiving general ward care and from patients hospitalised at intensive care units (ICUs) to explore the kinetics of circulating neutrophils and factors important for neutrophil migration and activation. METHODS Multicolour flow cytometry was exploited for the analysis of neutrophil differentiation and activation markers. Multiplex and ELISA technologies were used for the quantification of protease, protease inhibitor, chemokine and cytokine concentrations in plasma. Neutrophil polarisation responses were evaluated microscopically. Gelatinolytic and metalloproteinase activity in plasma was determined using a fluorogenic substrate. Co-culturing healthy donor neutrophils with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) allowed us to investigate viral replication in neutrophils. RESULTS Upon ICU admission, patients displayed high plasma concentrations of granulocyte-colony-stimulating factor (G-CSF) and the chemokine CXCL8, accompanied by emergency myelopoiesis as illustrated by high levels of circulating CD10-, immature neutrophils with reduced CXCR2 and C5aR expression. Neutrophil elastase and non-metalloproteinase-derived gelatinolytic activity were increased in plasma from ICU patients. Significantly higher levels of circulating tissue inhibitor of metalloproteinase 1 (TIMP-1) in patients at ICU admission yielded decreased total MMP proteolytic activity in blood. COVID-19 neutrophils were hyper-responsive to CXCL8 and CXCL12 in shape change assays. Finally, SARS-CoV-2 failed to replicate inside human neutrophils. CONCLUSION Our study provides detailed insights into the kinetics of neutrophil phenotype and function in severe COVID-19 patients, and supports the concept of an increased neutrophil activation state in the circulation.
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Affiliation(s)
- Mieke Metzemaekers
- Laboratory of Molecular ImmunologyDepartment of Microbiology, Immunology and TransplantationRega Institute, KU LeuvenLeuvenBelgium
| | - Seppe Cambier
- Laboratory of Molecular ImmunologyDepartment of Microbiology, Immunology and TransplantationRega Institute, KU LeuvenLeuvenBelgium
| | - Marfa Blanter
- Laboratory of Molecular ImmunologyDepartment of Microbiology, Immunology and TransplantationRega Institute, KU LeuvenLeuvenBelgium
| | - Jennifer Vandooren
- Laboratory of ImmunobiologyDepartment of Microbiology, Immunology and TransplantationRega Institute, KU LeuvenLeuvenBelgium
| | - Ana Carolina de Carvalho
- Laboratory of Molecular ImmunologyDepartment of Microbiology, Immunology and TransplantationRega Institute, KU LeuvenLeuvenBelgium
- Brazilian Center for Research in Energy and Materials ‐ CNPEMBrazilian Biosciences National LaboratoryCampinasLNBioBrazil
- Laboratory of ImmunoinflammationDepartment of Genetics, Microbiology and ImmunologyInstitute of BiologyUniversity of Campinas (UNICAMP)CampinasBrazil
| | - Bert Malengier‐Devlies
- Laboratory of ImmunobiologyDepartment of Microbiology, Immunology and TransplantationRega Institute, KU LeuvenLeuvenBelgium
| | - Lore Vanderbeke
- Laboratory of Clinical Bacteriology and MycologyDepartment of Microbiology, Immunology and TransplantationKU LeuvenLeuvenBelgium
| | - Cato Jacobs
- Laboratory for Clinical Infectious and Inflammatory DisordersDepartment of Microbiology, Immunology and TransplantationKU LeuvenLeuvenBelgium
| | - Sofie Coenen
- Division of PediatricsUniversity Hospitals LeuvenLeuvenBelgium
| | - Erik Martens
- Laboratory of ImmunobiologyDepartment of Microbiology, Immunology and TransplantationRega Institute, KU LeuvenLeuvenBelgium
| | - Noëmie Pörtner
- Laboratory of Molecular ImmunologyDepartment of Microbiology, Immunology and TransplantationRega Institute, KU LeuvenLeuvenBelgium
| | - Lotte Vanbrabant
- Laboratory of Molecular ImmunologyDepartment of Microbiology, Immunology and TransplantationRega Institute, KU LeuvenLeuvenBelgium
| | - Pierre Van Mol
- Laboratory of Translational GeneticsDepartment of Human GeneticsVIB‐KU LeuvenLeuvenBelgium
| | - Yannick Van Herck
- Laboratory of Experimental OncologyDepartment of OncologyKU LeuvenLeuvenBelgium
| | - Nathalie Van Aerde
- Laboratory of Intensive Care MedicineDepartment of Cellular and Molecular MedicineKU LeuvenLeuvenBelgium
| | - Greet Hermans
- Laboratory of Intensive Care MedicineDepartment of Cellular and Molecular MedicineKU LeuvenLeuvenBelgium
| | - Jan Gunst
- Laboratory of Intensive Care MedicineDepartment of Cellular and Molecular MedicineKU LeuvenLeuvenBelgium
| | - Alexandre Borin
- Brazilian Center for Research in Energy and Materials ‐ CNPEMBrazilian Biosciences National LaboratoryCampinasLNBioBrazil
| | - Bruna Toledo N Pereira
- Laboratory of ImmunoinflammationDepartment of Genetics, Microbiology and ImmunologyInstitute of BiologyUniversity of Campinas (UNICAMP)CampinasBrazil
| | - Arilson Bernardo dos SP Gomes
- Laboratory of ImmunoinflammationDepartment of Genetics, Microbiology and ImmunologyInstitute of BiologyUniversity of Campinas (UNICAMP)CampinasBrazil
| | - Stéfanie Primon Muraro
- Laboratory Emerging VirusesDepartment of Genetics, Microbiology and ImmunologyInstitute of BiologyUniversity of Campinas (UNICAMP)CampinasBrazil
| | - Gabriela Fabiano de Souza
- Laboratory Emerging VirusesDepartment of Genetics, Microbiology and ImmunologyInstitute of BiologyUniversity of Campinas (UNICAMP)CampinasBrazil
| | - Alessandro S Farias
- Experimental Medicine Research Cluster (EMRC)University of Campinas (UNICAMP)CampinasBrazil
| | - José Luiz Proenca‐Modena
- Laboratory Emerging VirusesDepartment of Genetics, Microbiology and ImmunologyInstitute of BiologyUniversity of Campinas (UNICAMP)CampinasBrazil
- Experimental Medicine Research Cluster (EMRC)University of Campinas (UNICAMP)CampinasBrazil
| | - Marco Aurélio R Vinolo
- Laboratory of ImmunoinflammationDepartment of Genetics, Microbiology and ImmunologyInstitute of BiologyUniversity of Campinas (UNICAMP)CampinasBrazil
- Experimental Medicine Research Cluster (EMRC)University of Campinas (UNICAMP)CampinasBrazil
| | - Pedro Elias Marques
- Laboratory of Molecular ImmunologyDepartment of Microbiology, Immunology and TransplantationRega Institute, KU LeuvenLeuvenBelgium
| | - Carine Wouters
- Laboratory of ImmunobiologyDepartment of Microbiology, Immunology and TransplantationRega Institute, KU LeuvenLeuvenBelgium
- Division of Pediatric RheumatologyUniversity Hospitals LeuvenLeuvenBelgium
- European Reference Network for Rare ImmunodeficiencyAutoinflammatory and Autoimmune Diseases (RITA) at University Hospitals LeuvenLeuvenBelgium
| | - Els Wauters
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE)Department of Chronic Diseases and MetabolismKU LeuvenLeuvenBelgium
| | - Sofie Struyf
- Laboratory of Molecular ImmunologyDepartment of Microbiology, Immunology and TransplantationRega Institute, KU LeuvenLeuvenBelgium
| | - Patrick Matthys
- Laboratory of ImmunobiologyDepartment of Microbiology, Immunology and TransplantationRega Institute, KU LeuvenLeuvenBelgium
| | - Ghislain Opdenakker
- Laboratory of ImmunobiologyDepartment of Microbiology, Immunology and TransplantationRega Institute, KU LeuvenLeuvenBelgium
| | - Rafael Elias Marques
- Brazilian Center for Research in Energy and Materials ‐ CNPEMBrazilian Biosciences National LaboratoryCampinasLNBioBrazil
| | - Joost Wauters
- Laboratory for Clinical Infectious and Inflammatory DisordersDepartment of Microbiology, Immunology and TransplantationKU LeuvenLeuvenBelgium
| | - Mieke Gouwy
- Laboratory of Molecular ImmunologyDepartment of Microbiology, Immunology and TransplantationRega Institute, KU LeuvenLeuvenBelgium
| | - Paul Proost
- Laboratory of Molecular ImmunologyDepartment of Microbiology, Immunology and TransplantationRega Institute, KU LeuvenLeuvenBelgium
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Van Aerde N, Meersseman P, Debaveye Y, Wilmer A, Gunst J, Casaer MP, Wauters J, Wouters PJ, Gosselink R, Van den Berghe G, Hermans G. Five-year outcome of respiratory muscle weakness at intensive care unit discharge: secondary analysis of a prospective cohort study. Thorax 2021; 76:561-567. [PMID: 33712505 DOI: 10.1136/thoraxjnl-2020-216720] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 12/08/2020] [Revised: 02/02/2021] [Accepted: 02/18/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE To assess the association between respiratory muscle weakness (RMW) at intensive care unit (ICU) discharge and 5-year mortality and morbidity, independent from confounders including peripheral muscle strength. METHODS Secondary analysis of the prospective 5-year follow-up of the EPaNIC cohort (ClinicalTrials.gov: NCT00512122), limited to 366 patients screened for respiratory and peripheral muscle strength in the ICU with maximal inspiratory pressure (MIP) after removal of the artificial airway, and the Medical Research Council sum score. RMW was defined as an absolute value of MIP <30 cmH2O. Associations between RMW at (or closest to) ICU discharge and all-cause 5-year mortality, and key measures of 5-year physical function, comprising respiratory muscle strength (MIP), hand-grip strength (HGF), 6 min walk distance (6MWD) and physical function of the SF-36 quality-of-life questionnaire (PF-SF-36), were assessed with Cox proportional hazards and linear regression models, adjusted for confounders including peripheral muscle strength. RESULTS RMW was present in 136/366 (37.2%) patients at ICU discharge. RMW was not independently associated with 5-year mortality (HR with 95% CI 1.273 (0.751 to 1.943), p=0.352). Among 156five-year survivors, those with, as compared with those without RMW demonstrated worse physical function (MIP (absolute value, cmH2O): 62(42-77) vs 94(78-109), p<0.001; HGF (%pred): 67(44-87) vs 96(68-110), p<0.001; 6MWD (%pred): 87(74-102) vs 99 (80-111), p=0.009; PF-SF-36 (score): 55 (30-80) vs 80 (55-95), p<0.001). Associations between RMW and morbidity endpoints remained significant after adjustment for confounders (effect size with 95% CI: MIP: -23.858 (-32.097 to -15.027), p=0.001; HGF: -18.591 (-30.941 to -5.744), p=0.001; 6MWD (transformed): -1587.007 (-3073.763 to -179.253), p=0.034; PF-SF-36 (transformed): 1.176 (0.144-2.270), p=0.036). CONCLUSIONS RMW at ICU discharge is independently associated with 5-year morbidity but not 5-year mortality.
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Affiliation(s)
| | - Philippe Meersseman
- Medical Intensive Care Unit, Department of General Internal Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Yves Debaveye
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium.,Intensive Care Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Alexander Wilmer
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium.,Medical Intensive Care Unit, Department of General Internal Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Jan Gunst
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium.,Intensive Care Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Michael P Casaer
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium.,Intensive Care Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Joost Wauters
- Medical Intensive Care Unit, Department of General Internal Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium.,Laboratory for Clinical Infectious and Inflammatory Disorders, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Flanders, Belgium
| | - Pieter J Wouters
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium.,Intensive Care Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Rik Gosselink
- Rehabilitation Sciences, KU Leuven, Leuven, Flanders, Belgium
| | - Greet Van den Berghe
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium.,Intensive Care Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Greet Hermans
- Cellular and Molecular Medicine, KU Leuven, Leuven, Flanders, Belgium .,Medical Intensive Care Unit, Department of General Internal Medicine, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
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7
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Affiliation(s)
- Nathalie Van Aerde
- Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Greet Van den Berghe
- Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Intensive Care Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Greet Hermans
- Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
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Kherad O, Peiffer-Smadja N, Karlafti L, Lember M, Aerde NV, Gunnarsson O, Baicus C, Vieira MB, Vaz-Carneiro A, Brucato A, Lazurova I, Leśniak W, Hanslik T, Hewitt S, Papanicolaou E, Boeva O, Dicker D, Ivanovska B, Yldiz P, Lacor P, Cranston M, Weidanz F, Costantino G, Montano N. The challenge of implementing Less is More medicine: A European perspective. Eur J Intern Med 2020; 76:1-7. [PMID: 32303454 DOI: 10.1016/j.ejim.2020.04.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/12/2020] [Accepted: 04/04/2020] [Indexed: 01/05/2023]
Abstract
The concept of Less is More medicine emerged in North America in 2010. It aims to serve as an invitation to recognize the potential risks of overuse of medical care that may result in harm rather than in better health, tackling the erroneous assumption that more care is always better. In response, several medical societies across the world launched quality-driven campaigns ("Choosing Wisely") and published "top-five lists" of low-value medical interventions that should be used to help make wise decisions in each clinical domain, by engaging patients in conversations about unnecessary tests, treatments and procedures. However, barriers and challenges for the implementation of Less is More medicine have been identified in several European countries, where overuse is rooted in the culture and demanded by a society that requests certainty at almost any cost. Patients' high expectations, physician's behavior, lack of monitoring and pernicious financial incentives have all indirect negative consequences for medical overuse. Multiple interventions and quality-measurement efforts are necessary to widely implement Less is More recommendations. These also consist of a top-five list of actions: (1) a novel cultural approach starting from medical graduation courses, up to (2) patient and society education, (3) physician behavior change with data feedback, (4) communication training and (5) policy maker interventions. In contrast with the prevailing maximization of care, the optimization of care promoted by Less is More medicine can be an intellectual challenge but also a real opportunity to promote sustainable medicine. This project will constitute part of the future agenda of the European Federation of Internal Medicine.
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Affiliation(s)
- Omar Kherad
- Department of Internal Medicine, La Tour Hospital and University of Geneva, Geneva, Switzerland.
| | - Nathan Peiffer-Smadja
- Assistance Publique - Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Paris, France
| | - Lina Karlafti
- 1st Proedeutic Internal Medicine Clinic, AHEPA University Hospital of Thessaloniki, Aristotle University of Thessaloniki, Greece
| | - Margus Lember
- Department of Internal Medicine, University of Tartu and University Hospital, Tartu, Estonia
| | - Nathalie Van Aerde
- Invited member of the Belgian Society of Internal Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Orvar Gunnarsson
- Department of Internal Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - Cristian Baicus
- Department of Internal Medicine, Carol Davila University of Medicine and Pharmacy, Colentina University Hospital, Bucharest, Romania
| | - Miguel Bigotte Vieira
- Serviço de Nefrologia, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Centro de Estudos de Medicina Baseados na Evidência, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisboa, Portugal; Cochrane Portugal, Lisboa, Portugal
| | - António Vaz-Carneiro
- Centro de Estudos de Medicina Baseados na Evidência, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisboa, Portugal; Cochrane Portugal, Lisboa, Portugal
| | - Antonio Brucato
- Department of Biomedical and Clinical Sciences, University of Milan, Fatebenefratelli Hospital, Milan, Italy
| | - Ivica Lazurova
- PJ Safarik University I. Internal Clinic, Kosice, Slovakia
| | - Wiktoria Leśniak
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Thomas Hanslik
- Assistance Publique - Hôpitaux de Paris, Hôpital Ambroise Paré, Paris, France
| | - Stephen Hewitt
- Medical Division, Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Norway
| | | | - Olga Boeva
- Imaging Department, Stavropol State Medical University and Stavropol Territory Hospital, Russian Federation
| | - Dror Dicker
- Department of Internal Medicine, Rabin Medical Center, Petah Tikva, Israel
| | - Biljana Ivanovska
- Private Health Organization, Office of Internal Medicine, Skopje, Macedonia
| | - Pinar Yldiz
- Department of Internal Medicine İstanbul, Eskisehir Osmangazi University, Eskişehir, Turkey
| | - Patrick Lacor
- Department of Internal Medicine and Infectiology, Universitair Ziekenhuis, Brussel, Belgium
| | - Mark Cranston
- MBBS Hinchingbrooke Hospital, Huntingdon, United Kingdom
| | | | - Giorgio Costantino
- IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, and Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Nicola Montano
- IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, and Department of Clinical Science and Community Health, University of Milan, Milan, Italy.
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