[Osmotic demyelination syndrome and overly rapid correction of hyponatremia]

Hyponatremia is a frequent condition in hospitalized patients and is associated with significant morbidity and mortality. An association between rapid correction of hyponatremia and the occurrence of osmotic demyelination syndrome has been reported. Osmotic demyelination syndrome may present with severe neurologic symptoms, including in rare cases locked-in. Therefore, rapid correction of hyponatremia is recommended only in the presence of severe symptoms. In those cases, hypertonic saline (NaCl 3% 2 ml/Kg over 20 minutes) is recommended with close plasma sodium monitoring. After symptoms improvement, increases in sodium concentration should not exceed 8 mmol/l/24h. In cases without severe neurologic symptoms, the use of 3% NaCl solution should be avoided, and management should target the underlying causes of hyponatremia.

P-297 Regulation and functions of PGRMC1 in the human endometrium and in endometriosis

Study question

What is the role of PGRMC1 in the human endometrium (especially in tissue remodeling) and its potential contribution to the development of endometrial diseases?

Summary answer

In primary endometrial stromal cell culture, PGRMC1 downregulation modifies expression of genes implicated in extracellular matrix remodeling as well as in cell migration and invasion.

What is known already

It has been suggested that Progesterone Receptor Membrane Component-1 (PGRMC1) is involved in gynecological pathologies. In particular, Pgrmc1 conditional KO in the mouse female reproductive tract induced subfertility and spontaneous development of endometrial cysts. Moreover, siRNA-mediated downregulation of PGRMC1 expression influenced TNF-α-induced activity of matrix metalloproteinase-9 (MMP-9) in cytotrophoblast cells, suggesting that PGRMC1 is a regulator of MMPs. In addition to playing a major role in the physiological breakdown of the human endometrium at menstruation, MMPs are strongly suspected to favor the pathogenesis of endometriosis lesions.

Study design, size, duration

Not applicable

Participants/materials, setting, methods

We compared transcriptomes obtained by RNA-sequencing from distinct primary endometrial stromal cell (ESC) cultures transfected with one of two specific siRNA targeting PGRMC1 mRNA or with a control siRNA. Expression changes for selected genes were confirmed by RT-qPCR. Migration and invasion capacities of the cells were also studied using Transwell assay. Finally, immunocytochemistry was performed on these primary cultures to localize the presence of PGRMC1 as well as the canonical progesterone receptor (PR).

Main results and the role of chance

RNA-sequencing data converged to show that the reduction of PGRMC1 expression by the specific siRNA significantly increased (up to 3-fold) the expression of several genes involved in the extracellular matrix (ECM) remodeling, as well as in the processes of migration and invasion. These changes were reproduced by RT-qPCR on other distinct primary endometrial stromal cultures isolated from other patients. In parallel, Transwell assays showed no significant changes in the migration and invasion capacities of the primary endometrial stromal cell cultures previously invalidated for PGRMC1 by transfection of the cells with a specific siRNA by comparison with a control siRNA. However, immunocytochemistry studies on these primary endometrial stromal cells showed that progesterone receptor (PR) labeling was restricted to cell nuclei, suggesting a constitutively activated PR in these cultures.

Limitations, reasons for caution

The absence of changes in migration and invasion properties of primary ESC cultures observed by Transwell assay could be due to the fact that the progesterone receptor seems to be constitutively activated in these cultures potentially causing a repressive effect on the migration and invasion capacity of the cells.

Wider implications of the findings

The modification of expression of genes implicated in ECM remodeling, and cell migration and invasion after PGRMC1 downregulation in primary ESC cultures is interesting in the context of endometriosis in which reduction of PGRMC1 expression could improve the migration and invasion capacities of lesions to implant into the host tissue.

Trial registration number

Not applicable

Decreased CRRT Filter Lifespan in COVID-19 ICU Patients

(1) Background: Increased thromboembolic events and an increased need for continuous renal replacement therapy (CRRT) have been frequently reported in COVID-19 patients. Our aim was to investigate CRRT filter lifespan in intensive care unit (ICU) COVID-19 patients. (2) Methods: We compared CRRT adjusted circuit lifespan in COVID-19 patients admitted for SARS-CoV-2 infection to a control group of patients admitted for septic shock of pulmonary origin other than COVID-19. Both groups underwent at least one session of CRRT for AKI. (3) Results: Twenty-six patients (13 in each group) were included. We analysed 117 CRRT circuits (80 in the COVID-19 group and 37 in the control group). The adjusted filter lifespan was shorter in the COVID-19 group (17 vs. 39 h, p < 0.001). This trend persisted after adjustment for confounding factors (-14 h, p = 0.037). Before CRRT circuit clotting, the COVID-19 group had a more procoagulant profile despite higher heparin infusion rates. Furthermore, we reported a decreased relation between activated partial thromboplastin time (aPTT) and cumulative heparin dose in COVID-19 patients when compared to historical data of 23,058 patients, suggesting a heparin resistance. (4) Conclusion: COVID-19 patients displayed a shorter CRRT filter lifespan that could be related to a procoagulant profile and heparin resistance.

COVID-19 is Associated with an Unusual Pattern of Brain Microbleeds in Critically Ill Patients

BACKGROUND AND PURPOSE

Covid-19, initially described as a respiratory system's infection, is currently more and more recognized as a multiorganic disease, including neurological manifestations. There is growing evidence about a potential neuroinvasive role of SARS-CoV-2. The purpose of this study is to describe new findings, in the form of cerebral microbleeds affecting different brain structures, observed in MRIs of critically ill patients.

METHODS

For this purpose, the MR images of 9 patients with a common pattern of abnormal findings (2 women/7 men; 55-79 years of age; mean age: 67.7 years) were depicted. All patients were tested positive for SARS-CoV-2 and presented with delayed recovery of consciousness or important agitation, requiring brain MRI.

RESULTS

All patients had suffered from severe (5/9) or moderate (4/9) acute respiratory distress syndrome, requiring prolonged stay in the intensive care unit. Their common MRI finding was the presence of microbleeds in unusual distribution with a specific predilection for the corpus callosum. Other uncommon locations of microbleeds were the internal capsule (5/9), as well as middle cerebellar peduncles (5/9). Subcortical regions were also affected in the majority of patients.

CONCLUSIONS

Brain MRI raised evidence that Covid-19 or its related treatment may involve the brain with an unusual pattern of microbleeds, predominantly affecting the corpus callosum. The mechanism of this finding is still unclear but the differential diagnosis should include thrombotic microangiopathy related to direct or indirect-through the cytokine cascade-damage by the SARS-CoV-2 on the endothelium of brain's vessels, as well as mechanisms similar to the hypoxemia brain-blood-barrier injury.

Association between hydroxocobalamin administration and acute kidney injury after smoke inhalation: a multicenter retrospective study

Background

The use of hydroxocobalamin has long been advocated for treating suspected cyanide poisoning after smoke inhalation. Intravenous hydroxocobalamin has however been shown to cause oxalate nephropathy in a single-center study. The impact of hydroxocobalamin on the risk of acute kidney injury (AKI) and survival after smoke inhalation in a multicenter setting remains unexplored.

Methods

We conducted a multicenter retrospective study in 21 intensive care units (ICUs) in France. We included patients admitted to an ICU for smoke inhalation between January 2011 and December 2017. We excluded patients discharged at home alive within 24 h of admission. We assessed the risk of AKI (primary endpoint), severe AKI, major adverse kidney (MAKE) events, and survival (secondary endpoints) after administration of hydroxocobalamin using logistic regression models.

Results

Among 854 patients screened, 739 patients were included. Three hundred six and 386 (55.2%) patients received hydroxocobalamin. Mortality in ICU was 32.9% (n = 243). Two hundred eighty-eight (39%) patients developed AKI, including 186 (25.2%) who developed severe AKI during the first week. Patients who received hydroxocobalamin were more severe and had higher mortality (38.1% vs 27.2%, p = 0.0022). The adjusted odds ratio (95% confidence interval) of AKI after intravenous hydroxocobalamin was 1.597 (1.055, 2.419) and 1.772 (1.137, 2.762) for severe AKI; intravenous hydroxocobalamin was not associated with survival or MAKE with an adjusted odds ratio (95% confidence interval) of 1.114 (0.691, 1.797) and 0.784 (0.456, 1.349) respectively.

Conclusion

Hydroxocobalamin was associated with an increased risk of AKI and severe AKI but was not associated with survival after smoke inhalation.

Trial registration

ClinicalTrials.gov, NCT03558646

Microsurgical anatomy of branches of musculocutaneous nerve: clinical relevance for spastic elbow surgery

PURPOSE

The neurotomy of musculocutaneous nerve is a treatment for patients who suffer from spastic elbow flexion when medical and reeducative treatments have failed. It consists in sectioning motor branches of musculocutaneous nerve which are destined to the biceps brachii and brachialis muscles, both being the main elbow flexor muscles. The aim of this study was to analyse the distance, where each motor branch arises from the musculocutaneous nerve to both biceps brachii and brachialis muscles, to establish precisely the localisation and length of the necessary incision to reach its branches for surgery.

MATERIALS AND METHODS

Eighteen musculocutaneous nerves from ten cadavers were dissected. None of them reported with a previous pathology. The cadavers were laid on the back with 30-35° of abduction, a complete extension, and supination of the upper limb.

RESULTS

The localization of motor branches was to be found in the middle third of the upper arm, with an average from the base of the humeral major tubercle of 11.46, 12.40, and 12.87 cm for the biceps brachii and 16.36, 19.10, and 16.88 cm for the brachialis muscle.

CONCLUSION

The incision needed to reach the motor branches of the musculocutaneous nerve should be localised between 10 and 20 cm from the major humeral tubercle and may be shorter than usual.

Tryptophan catabolism in Pseudomonas aeruginosa and potential for inter-kingdom relationship

BACKGROUND

Pseudomonas aeruginosa (Pa) is a Gram-negative bacteria frequently involved in healthcare-associated pneumonia with poor clinical outcome. To face the announced post-antibiotic era due to increasing resistance and lack of new antibiotics, new treatment strategies have to be developed. Immunomodulation of the host response involved in outcome could be an alternative therapeutic target in Pa-induced lung infection. Kynurenines are metabolites resulting from tryptophan catabolism and are known for their immunomodulatory properties. Pa catabolizes tryptophan through the kynurenine pathway. Interestingly, many host cells also possess the kynurenine pathway, whose metabolites are known to control immune system homeostasis. Thus, bacterial metabolites may interfere with the host's immune response. However, the kynurenine pathway in Pa, including functional enzymes, types and amounts of secreted metabolites remains poorly known. Using liquid chromatography coupled to mass spectrometry and different strains of Pa, we determined types and levels of metabolites produced by Pa ex vivo in growth medium, and the relevance of this production in vivo in a murine model of acute lung injury.

RESULTS

Ex vivo, Pa secretes clinically relevant kynurenine levels (μM to mM). Pa also secretes kynurenic acid and 3-OH-kynurenine, suggesting that the bacteria possess both a functional kynurenine aminotransferase and kynurenine monooxygenase. The bacterial kynurenine pathway is the major pathway leading to anthranilate production both ex vivo and in vivo. In the absence of the anthranilate pathway, the kynurenine pathway leads to kynurenic acid production.

CONCLUSION

Pa produces and secretes several metabolites of the kynurenine pathway. Here, we demonstrate the existence of new metabolic pathways leading to synthesis of bioactive molecules, kynurenic acid and 3-OH-kynurenine in Pa. The kynurenine pathway in Pa is critical to produce anthranilate, a crucial precursor of some Pa virulence factors. Metabolites (anthranilate, kynurenine, kynurenic acid) are produced at sustained levels both ex vivo and in vivo leading to a possible immunomodulatory interplay between bacteria and host. These data may imply that pulmonary infection with bacteria highly expressing the kynurenine pathway enzymes could influence the equilibrium of the host's tryptophan metabolic pathway, known to be involved in the immune response to infection. Further studies are needed to explore the effects of these metabolic changes on the pathophysiology of Pa infection.

Surviving a Massive Sodium Azide Poisoning with Toxic Cardiomyopathy

Sodium azide is a highly toxic chemical agent, which effects are similar to cyanide, and its ingestion is almost constantly fatal when the dose is above 1g. We report the case of a 69-year-old woman who survived a massive sodium azide poisoning with an unsual clinical course and outcome. It caused severe toxic cardiomyopathy presenting like a silent myocardial infaction with systolic and diastolic impairment that lasted one month. There is no antidote. We present a review of the literature about this rare poisoning, its mechanisms and discuss treatment options.