Invasive Pulmonary Aspergillosis in Critically Ill Patients with Hantavirus Infection, Austria

We investigated a cohort of 370 patients in Austria with hantavirus infections (7.8% ICU admission rate) and detected 2 cases (cumulative incidence 7%) of invasive pulmonary aspergillosis; 1 patient died. Hantavirus-associated pulmonary aspergillosis may complicate the course of critically ill patients who have hemorrhagic fever with renal syndrome.

Ruxolitinib, IV Immunoglobulin, and High-Dose Glucocorticoids for Critically Ill Adults With Secondary Hemophagocytic Lymphohistiocytosis: A Single-Center Observational Pilot Study

OBJECTIVES

Secondary hemophagocytic lymphohistiocytosis (sHLH) is a cytokine-driven inflammatory syndrome that is associated with substantial morbidity and mortality and frequently leads to ICU admission. Overall survival in adults with sHLH remains poor, especially in those requiring intensive care. Classical chemotherapeutic treatment exhibits myelosuppression and toxicity. Recently, inhibition of Janus kinase signaling by ruxolitinib has shown efficacy in pediatric HLH. We therefore aimed to determine the activity and safety of a ruxolitinib-based regimen, in critically ill adults with sHLH.

DESIGN

Observational pilot study.

SETTING

Single-center tertiary academic ICU.

PATIENTS

Nine adults (≥ 18 yr) who fulfilled at least five of the eight HLH-2004 criteria.

INTERVENTION

Triplet regimen combining: 1) ruxolitinib, 2) polyvalent human IV immunoglobulins (IVIG) at a dose of 1 g/kg bodyweight for 5 days, and 3) high-dose corticosteroids (CSs, dexamethasone 10 mg/m² body surface area, or methylprednisolone equivalent) with subsequent tapering according to the HLH-2004 protocol.

MEASUREMENT AND MAIN RESULTS

Nine patients (median age: 42 yr [25th-75th percentile: 32-54]; male: n = 6 males, median H-score: 299 [255-304]) were treated with the triplet regimen. The median Sequential Organ Failure Assessment score at HLH diagnosis was 9 (median; 25th-75th percentile: 7-12), indicating multiple-organ dysfunction in all patients. Within 10 days a significant decrease of the inflammatory parameters soluble interleukin-2 receptor and ferritin as well as a stabilization of the blood count could be shown. All patients were alive at ICU discharge (100% ICU survival), 1 patient died after ICU discharge because of traumatic intracerebral hemorrhage that might be related to HLH or treatment, corresponding to an overall survival of 86% in a 6 months follow-up period.

CONCLUSION

In this small case series, a triplet regimen of ruxolitinib in combination with IVIG and CS was highly effective and save for treating critically ill adults with sHLH.

Biomarkers of alcohol abuse potentially predict delirium, delirium duration and mortality in critically ill patients

Carbohydrate-deficient transferrin (CDT) and the γ-glutamyltransferase-CDT derived Anttila-Index are established biomarkers for sustained heavy alcohol consumption and their potential role to predict delirium and mortality in critically ill patients is not clear. In our prospective observational study, we included 343 consecutive patients admitted to our ICU, assessed the occurrence of delirium and investigated its association with biomarkers of alcohol abuse measured on the day of ICU admission. 35% of patients developed delirium during ICU stay. We found significantly higher CDT levels (p = 0.011) and Anttila-Index (p = 0.001) in patients with delirium. CDT above 1.7% (OR 2.06), CDT per percent increase (OR 1.26, AUROC 0.75), and Anttila-Index per unit increase (OR 1.28, AUROC 0.74) were associated with delirium development in adjusted regression models. Anttila-Index and CDT also correlated with delirium duration exceeding 5 days. Additionally, Anttila-Index above 4, Anttila-Index per unit increase, and CDT per percent increase were independently associated with hospital mortality.

[Inpatient rehabilitation of chronic schizophrenic patients with a behavior therapy token reinforcement program]

The efficacy of a token economy system was assessed in a study involving 76 chronic schizophrenics who were inpatients during a treatment period of four years. The interrelations between therapeutic success on the one hand, and socio-economic as well as course of disease-related factors on the other were studied, including psychopathology and the efficacy of token economy.

The fine structure of denervated and reinnervated muscle spindles: morphometric study of intrafusal muscle fibers

The fine structure of normal, denervated, and reinnervated muscle spindles in lower lumbrical muscles of rats was studied morphometrically at time intervals ranging from 3-14 months. In control spindles, the mean transverse area of mitochondria was estimated to be more than twice as large in nuclear chain than in typical nuclear bag fibers. Following denervation, there was a severe decrease of the mean number and transverse area of mitochondria, and a moderate, but statistically significant decrease of the mean transverse area of intrafusal muscle fibers (IMFs) despite an increase of the number of IMFs. At 12-14 months of reinnervation, changes of the transverse areas of IMFs were statistically insignificant, but the mean values for the mitochondria were incompletely restored. At 4 x 3 months, after fourfold repeated crush injuries to the nerve, most of the values estimated (transverse area of mitochondria; number, shape, and transverse area of IMFs and nuclei) tended to approach those in denervated rather than in reinnervated IMFs. The differences of the reactions of intra- and extrafusal muscle fibers following complete motor and sensory denervation appeared to be in accordance with their normal dimensional dissimilarities.