Des tumeurs surrénaliennes bilatérales Esnault, H.; Lahaye, C.; Girard, L. ...
La revue de medecine interne,
January 2020, 2020-01-00, Letnik:
41, Številka:
1
Journal Article
Background Dexamethasone is standard of care for the treatment of patients with COVID-19 requiring oxygen. The objective is to assess the clinical benefit of adding remdesivir to dexamethasone. ...Patients and methods A retrospective cohort study of hospitalized patients with COVID-19 pneumonia requesting low-flow oxygen who received dexamethasone. Patients admitted to infectious diseases wards also received remdesivir. Primary outcome was duration of hospitalization after oxygen initiation. Secondary outcomes were in-hospital death, and death and/or transfer to the intensive care unit. To handle potential confounding by indication bias, outcome comparison was performed on propensity score-matched populations. Propensity score was estimated by a multivariable logistic model including prognostic covariates; then 1:1 matching was performed without replacement, using the nearest neighbor algorithm with a caliper of 0.10 fold the standard deviation of the propensity score as the maximal distance. Balance after matching was checked on standardized mean differences. Results From August 15th 2020, to February 28th, 2021, 325 patients were included, 101 of whom received remdesivir. At admission median time from symptoms onset was 7 days, median age: 68 years, male sex; 61%, >1 comorbidity: 58.5%. Overall 180 patients matched on propensity score were analyzed, 90 each received remdesivir plus dexamethasone or dexamethasone alone. Median duration of hospitalization was 9 (IQR: 7–13) and 9 (IQR: 5–18) days with and without remdesivir, respectively (p = 0.37). In-hospital death rates and rates of transfer to the intensive care unit or death were 8.9 and 17.8% (HR: 0.46, 95% CI: 0.21–1.02, p = 0.06) and 20.0 and 35.6% with and without remdesivir, respectively (HR: 0.45, 95% CI: 0.23–0.89, p = 0.015). Conclusion In hospitalized patients with COVID-19 pneumonia receiving low-flow oxygen and dexamethasone, the addition of remdesivir was not associated with shorter hospitalization or lower in-hospital mortality but may have reduced the combined outcome of death and transfer to the intensive care unit.
In sponges, as in other taxa with simple organization, the evaluation and use of morphological characters is difficult. Phylogenetic analysis of the first 850 nucleotides from the 5' end of the 28S ...rRNA gene is used here to assess the homology of spicules used in the classification of the subclass Tetractinellida. A single well-supported MP tree was obtained. The monophyly of the nine Tetractinellida species studied confirms the tetraxon megasclere as a morphological synapomorphy forthe Tetractinellida.Two species are reallocated, Penareshelleri as a Geodiidae,now thought to have lost sterrastermicroscleres, and Stryphnus mucronatus to the Streptosclerophorida. SEM micrographs of Stryphnus microscleres show that the morphology of the sanidasters is compatible with the hypothesis that they are homologous with streptoscleres and confirm this reallocation. Two other synapomorphies are confirmed within the tetractinellid clade, the simultaneous presence of tetraxon megasclere and aster-type microsclere (Astrophorida) and the loss of the streptosclere and persistence of the euaster s.s. microscleres (Euastrophorida) evidenced by the reallocation of Stryphnus mucronatus. The streptosclere microscleres cannot be evaluated in terms of homology because Streptosclerophorida may be paraphyletic (although these nodes are not supported by reliable bootstrap proportions) contrary to the currently accepted classification.
Protein A immunoadsorption (IA) has proved effective in reducing proteinuria in patients with nephrotic syndrome after recurrence of focal and segmental glomerulosclerosis (FSGS) in kidney ...transplants. The effect of IA in nephrotic syndrome of other etiologies remains unknown. Nine patients with nephrotic syndrome secondary to membranous nephropathy (four cases), diabetes mellitus (one case), IgA nephropathy (two cases), and amyloidosis (two cases) had three to five IA of 2.5 plasma volumes over 4 to 8 d. Patients received no concomitant immunosuppressive treatment, and antihypertensive drugs were left unchanged. Proteinuria decreased from 12.64 +/- 5.49 to 3.35 +/- 2.2 g/24 h (mean +/- SD) in all patients after three to five IA. Hematocrit decreased from 37.32 to 32.64% (12.5% hemodilution) and serum albumin from 25.43 to 18.6 g/L (26.4% decrease). Proteinuria returned to baseline levels within 1 mo, as described in recurrent FSGS following transplantation. When serum albumin balance was controlled by albumin infusion after IA in two patients, comparable decreases in proteinuria were observed. Therefore, IA is effective in producing short-term reduction of proteinuria in nephrotic syndromes related not only to FSGS but also to membranous and IgA nephropathies, diabetes mellitus, and amyloidosis, which suggests that IA removes a nonspecific circulating hemodynamic-altering or permeability-increasing factor.
Background The COVID-19 pandemic is a heavy burden in terms of health care resources. Future decision-making policies require consistent data on the management and prognosis of the older patients (> ...70 years old) with COVID-19 admitted in the intensive care unit (ICU). Methods Characteristics, management, and prognosis of critically ill old patients (> 70 years) were extracted from the international prospective COVID-ICU database. A propensity score weighted-comparison evaluated the impact of intubation upon admission on Day-90 mortality. Results The analysis included 1199 (28% of the COVID-ICU cohort) patients (median interquartile age 74 72-78 years). Fifty-three percent, 31%, and 16% were 70-74, 75-79, and over 80 years old, respectively. The most frequent comorbidities were chronic hypertension (62%), diabetes (30%), and chronic respiratory disease (25%). Median Clinical Frailty Scale was 3 (2-3). Upon admission, the PaO.sub.2/FiO.sub.2 ratio was 154 (105-222). 740 (62%) patients were intubated on Day-1 and eventually 938 (78%) during their ICU stay. Overall Day-90 mortality was 46% and reached 67% among the 193 patients over 80 years old. Mortality was higher in older patients, diabetics, and those with a lower PaO.sub.2/FiO.sub.2 ratio upon admission, cardiovascular dysfunction, and a shorter time between first symptoms and ICU admission. In propensity analysis, early intubation at ICU admission was associated with a significantly higher Day-90 mortality (42% vs 28%; hazard ratio 1.68; 95% CI 1.24-2.27; p < 0·001). Conclusion Patients over 70 years old represented more than a quarter of the COVID-19 population admitted in the participating ICUs during the first wave. Day-90 mortality was 46%, with dismal outcomes reported for patients older than 80 years or those intubated upon ICU admission.
With the current increase in sexually transmitted infections in industrialized countries, we assessed the characteristics and plasma viral load of HIV-1-infected patients reporting sexual behaviour ...at risk for HIV transmission (SBR).
The study population consisted of 223 patients with primary HIV-1 infection who were enrolled in the French PRIMO cohort between 1996 and 2001 and who had at least 3 months of follow-up. Patients were interviewed on condom use at each visit according to the partner (gender, steady versus casual nature, and HIV serostatus). SBR was defined as unprotected sex with partners of unknown or negative HIV serostatus.
Sixty-one SBR were reported by 43 patients. SBR with casual partners increased from 5.1% in 1998 to 21.1% in 2001-2002, after a fall between 1997 and 1998. Reporting of SBR was more frequent among patients with casual partners, those with asymptomatic or briefly (< or = 15 days) symptomatic primary infection, and those who had developed clinical lipodystrophy or signs of anxiety/depression. Eighty-six per cent of patients reporting SBR had previously initiated highly active antiretroviral therapy (HAART); plasma viral load was above the detection limit (200/500 copies/ml) in 41% of visits reporting an SBR. Viral load was similar in patients reporting SBR and other patients, suggesting that the patient's knowledge of his/her response to HAART was not a major determinant of subsequent SBR.
Our results confirm the recent increase in unsafe sex observed among HIV-infected individuals in industrialized countries. Levels of viral load of these individuals raise concern about the potential for re-emerging HIV epidemics.
Objectives
To describe the management of primary HIV infection (PHI), focusing on changes in the design of therapies and time to initiation of antiretroviral treatment, the clinical outcome, and the ...immuno‐virological response over time to highly active antiretroviral therapy (HAART) and its tolerance.
Design and methods
In the French PRIMO multicentre cohort, 291 patients presenting with PHI were enrolled between 1996 and 2001. Data were analysed to describe treatment prescription habits over a period of 5 years, and response to and tolerance of treatment.
Results
The proportion of patients who initiated treatment during PHI decreased from 92% in 1996 to 56% in 2001. At 6 months, whatever the initiated treatment, 74% of treated patients achieved a plasma viral load<400 HIV‐1 RNA copies/mL and 53% achieved a viral load of<50 copies/mL. Prescription of protease inhibitor (PI)‐sparing regimens has become more frequent since 1999. Despite a similar virological response, patients in the PI‐containing group tended to experience a greater 1‐year increase in CD4 cell count than those in the non‐nucleoside reverse transcriptase (NNRTI)‐containing group (218 cells/μL versus 157 cells/μL, respectively). An adverse event was recorded in 51% of treated patients. The most frequent events were gastrointestinal disorders (71%), lipodystrophy (27%) and mood disorders (19%). The main reason for modifying or stopping therapy was the occurrence of an adverse event.
Conclusions
Limitations of therapy and poor tolerance to antiretroviral regimens have changed physician attitudes in PHI. This suggests the need for evaluation of better‐tolerated regimens and new therapeutic strategies.
We evaluated the impact of genetic changes within p6Gag gene on the virological response (VR, mean decrease in plasma viral load at week 12) to unboosted amprenavir (APV). Gag-protease fragments, ...including gag p2, p7, p1, p6 regions and whole protease (PR) were sequenced from baseline plasma specimens of 84 highly pre-treated but APV-naive patients included in the NARVAL (ANRS 088) trial. The correlation between baseline p6Gag polymorphism, PR mutations, baseline characteristics and VR to APV was analysed in univariate analysis. Insertions (P459Ins) within p6 protein, leading to partial or complete duplication of the PTAPP motif, were significantly associated with a decreased VR (P459Ins versus wild-type; -0.3 +/- 0.8 vs -1.1 +/- 1.2 log copies/ml, P=0.007) and were more frequent when the V82A/F/T/S PR mutation was present (P=0.020). In multivariate analysis, after adjustment on the predictive factors of the VR in the NARVAL trial and on the PR mutations linked with response, there was a strong trend to an association (P=0.058) between the presence of P459Ins and an altered VR. In conclusion, these results suggest that insertions in the p6 region of HIV-1 gag gene may affect the VR, in highly pre-treated patients receiving an unboosted APV-containing regimen.
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