[Burns and Diabetes Mellitus: Epidemiology, Clinical Presentation and Prognosis]

Burns in diabetics are quite frequent and serious in relation to diabetic neuropathy, which is common in this population, delaying healing and predisposing to the risk of infection. The objective of this study was to describe the characteristics of burns in diabetics hospitalized at the CTB of Tunis over 18 months. During the study period, 891 patients were hospitalized, including 43 diabetics (5%). The average age of our patients was 57 years old with a male predominance (65%). Type 2 diabetes was present in 86% of cases and type 1 diabetes in 14% of cases. Degenerative complications were reported in 10 cases (23%), such as diabetic retinopathy (n=6), diabetic nephropathy (n=4) and diabetic neuropathy (n=6). The circumstances of burns were related to a domestic accident in 2/3 of the cases (76.7%). Thermal burns were involved in 83.7% of cases. 86% of the patients had decompensated their diabetes during their hospitalization. Sepsis marked the evolution of the patients in 55.8% of cases. In our study, poor prognostic factors were: a glycosylated haemoglobin > 13%, an extent of burns greater than 20%, and a delay in consultation greater than 6 hours. The mortality rate was 18.6%.

Comparative study of six SARS-CoV-2 serology assays: Diagnostic performance and antibody dynamics in a cohort of hospitalized patients for moderate to critical COVID-19

BACKGROUND

To overcome the COVID-19 pandemic, serology assays are needed to identify past and ongoing infections. In this context, we evaluated the diagnostic performance of 6 immunoassays on samples from hospitalized patients for moderate to critical COVID-19.

METHODS

701 serum samples obtained from 443 COVID-19 patients (G1: 356 positive RT-PCR patients and G2: 87 negative RT-PCR cases) and 108 pre-pandemic sera from blood donors were tested with 6 commercial immunoassays: (1) Elecsys Anti-SARS-CoV-2, Roche (Nucleocapsid, N), (2) Elecsys Anti-SARS-CoV-2 S, Roche (Spike, S), (3) Vidas SARS-COV-2 IgM/IgG, BioMérieux (S), (4) SARS-CoV-2 IgG, Abbott (N), (5) Access SARS-CoV-2 IgG, Beckman Coulter (Receptor Binding Domain), and (6) Standard F COVID-19 IgM/IgG Combo FIA, SD Biosensor (N).

RESULTS

Global sensitivities of the evaluated assays were as follows: (1) Roche anti-N = 74.5% [69.6-79.3], (2) Roche anti-S = 92.7% [84.7-100], (3) Vidas IgM = 74.9% [68.6-81.2], (4) Vidas IgG = 73.9% [67.6-80.1], (5) Abbott = 78.6% [63.4-93.8], (6) Beckman Coulter = 74.5% [62-86.9], (7) SD Biosensor IgM = 73.1% [61-85.1], and (8) SD Biosensor IgG = 76.9% [65.4-88.4]. Sensitivities increased gradually from week 1 to week 3 as follow: (1) Roche anti-N: 63.3%, 81% and 82.1%; (2) Vidas IgM: 68.2%, 83.2% and 85.9%; and (3) Vidas IgG: 66.7%, 79.1% and 86.6%. All immunoassays showed a specificity of 100%. Seropositivity was significantly associated with a higher frequency of critical COVID-19 (50.8% vs. 38.2%), p = 0.018, OR [95% CI] = 1.668 [1.09-2.553]. Inversely, death occurred more frequently in seronegative patients (28.7% vs. 13.6%), p=3.02 E-4, OR [95% CI] = 0.392 [0.233-0.658].

CONCLUSION

Evaluated serology assays exhibited good sensitivities and excellent specificities. Sensitivities increased gradually after symptoms onset. Even if seropositivity is more frequent in patients with critical COVID-19, it may predict a recovery outcome.

Les symptômes persistants de la COVID-19 à 3 mois

Introduction

Le syndrome de Covid long est défini par des symptômes qui persistent pendant plus de 4 semaines après une infection Covid, quel que soit sa gravité, et qui ne peuvent pas être expliqués par une autre cause. L’objectif de notre étude était d’étudier la prévalence de ce syndrome et de décrire les symptômes persistants.

Méthodes

Il s’agit d’une étude prospective descriptive ayant inclus les patients hospitalisés en octobre jusqu’à décembre 2020 au service de pneumologie du pavillon 2 de l’hôpital Abderahmen Mami. L’évaluation des symptômes persistants a été faite à 3 mois. Les données ont été obtenues lors du suivi des patients à l’aide d’un questionnaire standardisé.

Résultats

Cent cinquante patients ont été inclus. Le sex-ratio était égal à 1,5. L’âge moyen était de 63 ans [19–88 ans]. La durée moyenne d’hospitalisation était de 10,5 ± 7,2 jours. Cinquante-quatre patients (36 %) étaient tabagiques. L’IMC moyen était de 29,3 ± 5,9. C’étaient des formes cliniques modérée à sévère nécessitant une hospitalisation avec une atteinte scanographique jugée modérée à sévère (> 10 %) chez 114 patients (76 %). Tous les patients ont été mis sous oxygénothérapie, vitaminothérapie et anti-coagulation. Le transfert en réanimation a été indiqué dans 28 cas (18,6 %). Cent dix patients ont été régulièrement suivis à la consultation (73,3 %). Trente-huit patients (34,5 %) ont gardé une symptomatologie persistante à 3 mois : une fatigue ou une asthénie persistante dans 19 % des cas (21cas), des arthralgies dans 11,8 % des cas (13 cas), une dyspnée stade 1 mMRC dans 14,5 % des cas (16 cas), une dyspnée stade 2 mMRC dans 5,4 % (6 cas), une toux sèche dans 8,1 % des cas (9 cas) et 1 seul cas de sécheresse buccale persistante.

Conclusion

Le fardeau du COVID long est considérable et les effets persistants de cette maladie se répercuteront chez certains patients pendant plusieurs mois. Plusieurs études sont nécessaires afin de comprendre la physiopathologie de ce syndrome et de définir ses facteurs de risques.

Muscular hypotonia as an onset manifestation of Tuberculosis meningitis in an HIV-negative patient

Muscular hypotonia is considered as one of the rarest forms of initial onset signs of TBM, in addition to aphasia and hyponatremia, the awareness of those rare onset signs, a well-conducted diagnostic approach and early treatment can improve the outcome.

Prognostic Value of High-sensitivity Troponin I in Patients with Septic Shock: A Prospective Observational Study

BACKGROUND

Myocardial dysfunction is one of the mechanisms involved in the pathophysiology of septic shock. The role of troponin as a surrogate of myocardial injury in septic shock is still debated. The aim of this study was to assess the prognostic value of high-sensitivity cardiac troponin I (hs-cTnI) assay in predicting 28-day mortality in patients with septic shock.

MATERIALS AND METHODS

Prospective study including 75 patients with septic shock admitted to a medico-surgical ICU from January to December 2017. Patients under the age of 18 years, known pregnancy and patients in post-cardiac arrest were excluded. Clinical and demographic data including age, gender, comorbidities, SAPS II and SOFA scores were collected. Hs-cTnI was measured soon after admission and 12, 24, 48 and 72 after. Receiver operating characteristic (ROC) analysis was performed to identify the most useful troponin I cut-off level for the prediction of 28-day mortality. A p <0.05 was considered significant.

RESULTS

Seventy-five (M/F = 53/22) patients with septic shock were included in the study. The median SOFA and SAPS II scores were 10 and 42, respectively. The median duration of mechanical ventilation was 8 days and the median length of ICU stay was 11 days. The 28-day mortality was 54.6%. We found a high prevalence (47%) of elevated hs-cTnI in patients with septic shock. Median hs-cTnI on admission in the whole group was 36 ng/L. The 28-day mortality was found to be related to age (p <0.001), SAPS II score (p = 0.001), mean arterial pressure (p = 0.038), lactate (p <0.001) and glomerular filtration rate (p <0.001).Hs-cTnI levels were significantly higher in non-survival group than survival one at all time points: H12 (p = 0.006), H24 (p = 0.003), H48 (p = 0.005) and H72 (p=0.001). In multivariate analysis, hs-cTnI at H72 was independently associated with 28-day mortality.

CONCLUSION

Hs-cTnI elevation at 72 hours was associated with 28-day mortality in septic shock patients.

HOW TO CITE THIS ARTICLE

Jendoubi A, Jerbi S, Maamar E, Abbess A, Samoud Z, Kanzari L, et al. Prognostic Value of High-Sensitivity Troponin I in Patients with Septic Shock: A Prospective Observational Study. Indian J Crit Care Med 2019;23(7):320-325.

Efficacy and safety of Parecoxib for prevention of catheter-related bladder discomfort in patients undergoing transurethral resection of bladder tumor: Prospective randomised trial

Background and Aims:

Catheter-related bladder discomfort (CRBD) is the urge to void or discomfort in the suprapubic region secondary to an indwelling urinary catheter. We aimed to evaluate the safety and efficacy of single-dose of intravenous parecoxib in reducing the incidence and severity of CRBD in patients undergoing transurethral resection of bladder tumor (TURBT).

Methods:

Sixty-one adult patients, American Society of Anesthesiologists physical status I or II, undergoing elective TURBT under spinal anaesthesia, were randomly allocated to receive 40 mg of IV parecoxib (group P; n = 29) or an equal volume of normal saline (control group C; n = 32). CRBD was graded as none, mild, moderate, and severe. Between-group comparisons were made for the incidence and severity of CRBD, postoperative Visual analog scales (VAS), rescue analgesia equirements, and occurrence of adverse events. Statistical analysis done with the Mann–Whitney U-test and Fisher's Exact Test. A P value of ≤ 0.05 was considered statistically significant.

Results:

Parecoxib significantly reduced the incidence and severity of CRBD at 2, 4, 6, and 12 hours postoperatively compared to placebo (P < 0.05). Median pain VAS scores were lower in the P group at all times except the first hour. Rescue analgesia was given to more patients in group C (16/32, 50%) than in group P (1/29) (P < 0.001). None of the patients who received parecoxib experienced an adverse event.

Conclusion:

A single intravenous injection of parecoxib is safe and effective in decreasing the incidence and severity of CRBD in patients undergoing TURBT.

Trial Registration Identifier:

NCT02729935(www.clinicaltrials.gov).

NDM-1- and OXA-23-producing Acinetobacter baumannii isolated from intensive care unit patients in Tunisia

Gastrointestinal colonisation by carbapenem-resistant Acinetobacter baumannii (CRAB) is a critical step before nosocomial infection. This study evaluated CRAB intestinal carriage in patients admitted to a Tunisian ICU and determined the antimicrobial resistance mechanisms involved. From December 2014 to February 2015, all 63 patients admitted to the ICU were screened for rectal CRAB colonisation upon admission and once weekly thereafter. ICU patients who acquired a CRAB nosocomial infection were also included. β-Lactamases and associated resistance genes were screened by PCR sequencing, and molecular typing was performed by PFGE and MLST. The CRAB faecal carriage rate at admission was 4.8% (3/63). The CRAB acquisition rate during ICU stay was analysed in 39 of the remaining 60 patients and the rate of acquired CRAB faecal carriage was 15.4% (6/39); 4 patients also showed an ICU-acquired CRAB infection (one patient was a faecal carrier and suffered infection). Overall, 13 CRAB isolates were collected from 12 patients, of which 11 isolates showed resistance to all antibiotics tested except colistin. bla_OXA-23 and bla_NDM-1 were detected in 11 and 2 isolates, respectively. All OXA-23-producing strains carried armA, tetB, sul1 and catB, and some of them carried aph(3')-VIa, bla_TEM-1, aph(3')-Ia and ant(2'')-Ia. The bla_NDM-1-positive isolates harboured aph(3')-VIa and catB. Three PFGE patterns and two STs were identified [ST195 (n = 11), ST1089 (n = 2, NDM-1-positive)]. Whether imported or acquired during ICU stay, CRAB colonisation is a major risk factor for the occurrence of serious nosocomial infection. Systematic screening of faecal carriage is mandatory to prevent their spread.

[Safety and efficacy of intravenous tranexamic acid in endoscopic transurethral resections in urology: Prospective randomized trial]

BACKGROUND

Endoscopic urological procedures (transurethral resection of the prostate TURP/transurethral resection of bladder tumor TURBT) are not without risk of significant bleeding. This risk is due to the vascular nature of the tissues and their high levels of fibrinolytic enzymes in the tissues and urine. This study was conducted to evaluate the safety and efficacy of the antifibrinolytic agent tranexamic acid (TXA) in reducing blood loss in patients undergoing TURP/TURBT and transfusion requirement.

METHODS

This study was a prospective, randomized, double-blind, placebo controlled clinical trial. One hundred and thirty-one patients of ASA physical status I or II, undergoing TURP (60 patients) or TURBT (71 patients) were randomly allocated to receive IV TXA: bolus of 10mg/kg at the induction of anesthesia followed by infusion of 1mg/kg/h intraoperatively and for 24h postoperatively or an equal volume of saline (control group). Blood loss was evaluated in terms of reduction in the serum hemoglobin level (delta Hb=Hb H24-Hb H0).

RESULTS

There was no difference between two groups in terms of transfusion requirements and episodes of retention. TXA did not significantly reduce mean blood loss compared with placebo during TURP (1.37±0.69 vs. 1.72±1.23g/dL respectively, P=0.256) or TURBT (1.15±0.95 vs. 1.07±0.88g/dL; P=0.532). No thrombotic complications were noted in any patient.

CONCLUSION

Tranexamic acid did not reduce transfusion requirements or perioperative blood loss in transurethral resection of the prostate or bladder tumor.

LEVEL OF EVIDENCE

4.

A comparison between intravenous lidocaine and ketamine on acute and chronic pain after open nephrectomy: A prospective, double-blind, randomized, placebo-controlled study

BACKGROUND

Recently, there has been increasing interest in the use of analgesic adjuncts such as intravenous (IV) ketamine and lidocaine.

OBJECTIVES

To compare the effects of perioperative IV lidocaine and ketamine on morphine requirements, pain scores, quality of recovery, and chronic pain after open nephrectomy.

STUDY DESIGN

A prospective, randomized, placebo-controlled, double-blind trial.

SETTINGS

The study was conducted in Charles Nicolle University Hospital of Tunis.

METHODS

Sixty patients were randomly allocated to receive IV lidocaine: bolus of 1.5 mg/kg at the induction of anesthesia followed by infusion of 1 mg/kg/h intraoperatively and for 24 h postoperatively or ketamine: bolus of 0.15 mg/kg followed by infusion of 0.1 mg/kg/h intraoperatively and for 24 h postoperatively or an equal volume of saline (control group [CG]).

MEASUREMENTS

Morphine consumption, visual analog scale pain scores, time to the first passage of flatus and feces, postoperative nausea and vomiting (PONV), 6-min walk distance (6MWD) at discharge, and the incidence of chronic neuropathic pain using the "Neuropathic Pain Questionnaire" at 3 months.

RESULTS

Ketamine and lidocaine reduced significantly morphine consumption (by about 33% and 42%, respectively) and pain scores compared with the CG (P < 0.001). Lidocaine and ketamine also significantly improved bowel function in comparison to the CG (P < 0.001). Ketamine failed to reduce the incidence of PONV. The 6 MWD increased significantly from a mean ± standard deviation of 27 ± 16.2 m in the CG to 82.3 ± 28 m in the lidocaine group (P < 0.001). Lidocaine, but not ketamine, reduced significantly the development of neuropathic pain at 3 months (P < 0.05).

CONCLUSION

Ketamine and lidocaine are safe and effective adjuvants to decrease opioid consumption and control early pain. We also suggest that lidocaine infusion serves as an interesting alternative to improve the functional walking capacity and prevent chronic neuropathic pain at 3 months after open nephrectomy.

Pain Measurement in Mechanically Ventilated Patients with Traumatic Brain Injury: Behavioral Pain Tools Versus Analgesia Nociception Index

Introduction:

Pain is highly prevalent in critically ill trauma patients, especially those with a traumatic brain injury (TBI). Behavioral pain tools such as the behavioral pain scale (BPS) and critical-care pain observation tool are recommended for sedated noncommunicative patients. Analysis of heart rate variability (HRV) is a noninvasive method to evaluate autonomic nervous system activity. The analgesia nociception index (ANI) device (Physiodoloris^®, MDoloris Medical Systems, Loos, France) allows noninvasive HRV analysis. The ANI assesses the relative parasympathetic tone as a surrogate for antinociception/nociception balance in sedated patients. The primary aim of our study was to evaluate the effectiveness of ANI in detecting pain in TBI patients. The secondary aim was to evaluate the impact of norepinephrine use on ANI effectiveness and to determine the correlation between ANI and BPS.

Methods:

We performed a prospective observational study in 21 deeply sedated TBI patients. Exclusion criteria were nonsinus cardiac rhythm; presence of pacemaker; atropine or isoprenaline treatment; neuromuscular blocking agents; and major cognitive impairment. Heart rate, blood pressure, and ANI were continuously recorded using the Physiodoloris^® device at rest (T1), during (T2), and after the end (T3) of the painful stimulus (tracheal suctioning).

Results:

In total, 100 observations were scored. ANI was significantly lower at T2 (Median [min – max] 54.5 [22–100]) compared with T1 (90.5 [50–100], P < 0.0001) and T3 (82 [36–100], P < 0.0001). Similar results were found in the subgroups of patients with (65 measurements) or without (35) norepinephrine. During procedure, a negative linear relationship was observed between ANI and BPS (r² = −0.469, P < 0.001). At the threshold of 50, the sensitivity and specificity of ANI to detect patients with BPS ≥ 5 were 73% and 62%, respectively, with a negative predictive value of 86%.

Discussion:

Our results suggest that ANI is effective in detecting pain in ventilated sedated TBI patients, including those patients treated with norepinephrine.

High Prevalence of Gut Microbiota Colonization with Broad-Spectrum Cephalosporin Resistant Enterobacteriaceae in a Tunisian Intensive Care Unit

Healthcare-associated infections due to cefotaxime-resistant (CTX-R) Enterobacteriaceae have become a major public health threat, especially in intensive care units (ICUs). Often acquired nosocomially, CTX-R Enterobacteriaceae can be introduced initially by patients at admission. This study aimed to determine the prevalence and genetic characteristics of CTX-R Enterobacteriaceae-intestinal carriage in ICU patients, to evaluate the rate of acquisition of these organisms during hospitalization, and to explore some of the associated risk factors for both carriage and acquisition. Between December 2014 and February 2015, the 63 patients admitted in the ICU of Charles Nicolle hospital were screened for rectal CTX-R Enterobacteriaceae colonization at admission and once weekly thereafter to identify acquisition. CTX-R Enterobacteriaceae fecal carriage rate was 20.63% (13/63) at admission. Among the 50 non-carriers, 35 were resampled during their hospitalization and the acquisition rate was 42.85% (15/35). Overall, 35 CTX-R Enterobacteriaceae isolates were collected from 28 patients (25 Klebsiella pneumoniae, seven Escherichia coli, and three Enterobacter cloacae strains). Seven patients were simultaneously colonized with two CTX-R Enterobacteriaceae isolates. CTX-M-15 was detected in most of the CTX-R Enterobacteriaceae isolates (30/35, 88.23%). Three strains co-produced CMY-4 and 22 strains were carbapenem-resistant and co-produced a carbapenemase [OXA-48 (n = 13) or NDM-1 (n = 6)]. Molecular typing of K. pneumoniae strains, revealed eight Pulsed field gel electrophoresis (PFGE) patterns and four sequence types (ST) [ST101, ST147, ST429, and ST336]. However, E. coli isolates were genetically unrelated and belonged to A (n = 2), B1 (n = 2) and B2 (n = 3) phylogenetic groups and to ST131 (two strains), ST572 (two strains), ST615 (one strain) and ST617 (one strain). Five colonized patients were infected by CTX-R Enterobacteriaceae (four with the same strain identified from their rectal swab and one with a different strain). Whether imported or acquired during the stay in the ICU, colonization by CTX-R Enterobacteriaceae is a major risk factor for the occurrence of serious nosocomial infections. Their systematic screening in fecal carriage is mandatory to prevent the spread of these multidrug resistant bacteria.

Abstract P3-14-15: Lapatinib Plus Capecitabine in Trastuzumab Pre-Treated HER2- Positive Metastatic Breast Cancer: The Canadian Lapatinib Expanded Access Program Experience

BACKGROUND:

The global lapatinib expanded access programme (LEAP) provided access to lapatinib (L) combined with capecitabine (C) for women with HER2- positive metastatic breast cancer (MBC) who were previously treated with an anthracycline (A), taxane (T) and trastuzumab (TRAS) in 45 countries. The eligibility criteria and the dose of given drugs resembled that used in the phase III clinical trial EGF 100151, with the exception that patients (pts)previously exposed to C and pts with an ECOG performance status of 2 could be included as well. L is a dual tyrosine kinase inhibitor of EGFR and HER2. L plus C is an effective treatment option in T-refractory HER2-positive MBC. 148 Canadian pts were enrolled. METHODS:

LEAP enrolled patients with ErbB2-positive, locally advanced and MBC showing progressive disease following prior therapies with A, T, TRAS-containing regimens. Pts received L (1,250 mg/day) and C (2,000 mg/m2/day, days 1-14, every 21 days). We analyzed 148 Canadian LEAP pts recruited from seven centres for demographics, duration of therapy, L compliance, left ventricular function, progression-free survival (PFS), and overall survival (OS). RESULTS:

Data cut off for these analyses was Jan 10, 2010. [Data were not available for all 148 pts. The median age was 52 y (range 29-80 y) for 147 pts (145 women, 2 men). Ninety-five pts (64.6%) had no prior C and 52 (35.4%) had prior C (n=147). Study medication was discontinued for 142 pts (96.6%): 110 (74.8%) for progressive disease; 17 (11.6%) for adverse events; 8 (5.4%) for patient preference; and 3 (2%) were transitioned to the commercial supply of L. The median duration of therapy was 18.95 wk, ranging 0.1 to 96 wk (n=137). L compliance data showed that 73.7% of pts received ≥80% of the L dose (n=122). Median baseline left ventricular function (LVF) was 60%, ranging 50% to 81% (n=142). The median LVF at study end was 61%, ranging 37% to 83% (n = = 96). There was an amendment in June 2008 to end the collection of disease progression and/or death dates. Median PFS and OS were 22.1 wk (95% CI: 18.9-26.7), and 48 wk (95% CI: 42.3-…), respectively (n=71). CONCLUSIONS:

L combined with C is an effective option for women with refractory HER2-positive MBC. The results seen in the Canadian subset enrolled in LEAP were similar to the results of EGF 100151 and the Global LEAP in the efficacy and safety data.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-14-15.

[Experience of ambulatory anesthesia in Charles Nicolle hospital]

The authors report the experience of ambulatory surgery at Charles Nicoll's hospital on ophthalmology and ORL surgery in which 90% and 60% of acts can be realized on ambulatory. The organisation by means of structures and hospital workers makes an important gain. The anesthetic consultation, very important in this organisation, enable to avoid to rescue a patient at the last time.

[Inspiratory aid with facial masks during acute respiratory failure without hypercapnia]

This prospective study assessed, in 10 conscious patients without a history of chronic respiratory disease, the feasibility of mechanical pressure support ventilation with PEEP by face mask for the treatment of acute respiratory failure without hypercapnia. Pressure support level was determined to obtain a VT of 5 to 10 mL.kg-1 and a decrease of respiratory rate of more than 20%. FIO2 and PEEP levels were determined to obtain a SpO2 > 92% and a PaO2 > 70 mmHg. The efficiency of the technique was assessed through the time course of respiratory rate, PaO2, PaCO2 and SaO2. The technique was efficient in all patients and tracheal intubation was not required. During face mask ventilation, a significant decrease in respiratory rate and an increase in PaO2 and SaO2 were observed. Pressure support ventilation with PEEP by face mask is an efficient technique for the treatment of acute non hypercapnic respiratory failure in conscious and cooperative patients.