Objective
Takayasu arteritis (TAK) is a large‐vessel vasculitis that induces damage to the aorta and its branches. Glucocorticoids remain the gold standard of therapy for TAK. The nature of the T ...cells driving vascular inflammation and the effects of glucocorticoids on the systemic components of TAK are not understood. The aim of this study was to analyze T cell homeostasis and cytokine production in peripheral blood and inflammatory lesions of the aorta in patients with TAK.
Methods
T cell homeostasis and cytokine production in peripheral blood and inflammatory lesions of the aorta were analyzed using Luminex analysis, flow cytometry, and immunohistochemical analysis. The study included 41 patients fulfilling the American College of Rheumatology 1990 criteria for the classification of TAK (17 patients with active TAK and 24 patients with disease in remission), 30 patients with giant cell arteritis and 39 patients with Behçet's disease (disease controls), and 20 age‐ and sex‐matched healthy control subjects.
Results
We observed a marked increase in the expression of Th1 and Th17 cells, which correlated with TAK disease activity. The addition of serum from patients with active TAK to sorted CD4+ T cells from healthy donors in culture medium induced significant production of interferon‐γ (IFNγ) and interleukin‐17A (IL‐17A). We demonstrated the presence of IFNγ‐, IL‐6–, and IL‐17A–producing T cells in vascular inflammatory infiltrates in patients with TAK. Corticosteroid therapy was associated with decreased levels of circulating Th1 cytokines in corticosteroid‐treated patients with TAK compared with steroid‐free patients with TAK (for IL‐2, mean ± SD 5,079 ± 5,300 versus 7,359 ± 3,197 pg/ml; for IFNγ, 2,592 ± 3,072 versus 8,393 ± 3,392 pg/ml; for tumor necrosis factor α, 847 ± 724 versus 1,491 ± 392 pg/ml). However, glucocorticoids had essentially no effect on the frequency of Th17 cytokines (IL‐1 receptor, IL‐17, and IL‐23).
Conclusion
The Th17 and Th1 pathways contribute to the systemic and vascular manifestations of TAK. Glucocorticoid treatment suppresses Th1 cytokines but spares Th17 cytokines in patients with TAK.
Pancreatic surgery is associated with high morbidity, mainly due to infectious complications, so many centres use postoperative antibiotics (ATBpo) for all patients. However, antibiotic regimens vary ...according to local practices. The aims of this study were to describe the occurrence of surgical site infection (SSI) and ATBpo prescription after pancreatic surgery, and to determine the risk factors of postoperative SSI, in order to better define the clinical indications for ATBpo in this context.
All patients undergoing scheduled major pancreatic surgery from January 2007 to November 2018 were included in this retrospective study. Patients were classified into four groups according to SSI and routine ATBpo prescription: SSI+/ATBpo+, SSI-/ATBpo+, SSI+/ATBpo- and SSI-/ATBpo-. In addition, risk factors (fever and pre-operative biliary prosthesis) associated with the occurrence of SSI and ATBpo were analysed using a logistic regression model.
Data from 149 patients (115 pancreaticoduodenectomies and 34 splenopancreatectomies) were analysed. Thirty (20.1%) patients experienced SSI and 42 (28.2%) received ATBpo. No difference was found in routine ATBpo prescription between patients with and without SSI (26.7% vs 28.6%, respectively; P=0.9). Amongst the 107 patients who did not receive routine ATBpo, 85 (79.4%) did not develop an SSI. In-hospital mortality did not differ between infected and uninfected patients (7% vs 2%, respectively; P=0.13). The occurrence of postoperative fever differed between SSI+ and SSI- patients (73.3% vs 34.2%, respectively; P<0.001), while the prevalence of pre-operative biliary prosthesis was similar (37.9% vs 26.7%, respectively; P=0.3).
Non-routine ATBpo after major pancreatic surgery resulted in 85 (56%) patients being spared unnecessary antibiotic treatment. This suggests that routine ATBpo prescription could be excessive, but further studies are needed to confirm such antibiotic stewardship. Fever appears to be a relevant clinical sign for individual-based prescription, but the presence of a biliary prosthesis does not.
Due to collapse and cardiopulmonary resuscitation (CPR) maneuvers, major traumatic injuries may complicate the course of resuscitation for out-of-hospital cardiac arrest patients (OHCA). Our goals ...were to assess the prevalence of these injuries, to describe their characteristics and to identify predictive factors.
We conducted an observational study over a 9-year period (2007–2015) in a French cardiac arrest (CA) center. All non-traumatic OHCA patients admitted alive in the ICU were studied. Major injuries identified were ranked using a functional two-level scale of severity (life-threatening or consequential) and were classified as CPR-related injuries or collapse-related injuries, depending of the predominant mechanism. Factors associated with occurrence of a CPR-related injury and ICU survival were identified using multivariable logistic regression.
A major traumatic injury following OHCA was observed in 91/1310 patients (6.9%, 95%CI: 5.6, 8.3%), and was classified as a life-threatening injury in 36% of cases. The traumatic injury was considered as contributing to the death in 19 (21%) cases. Injuries were related to CPR maneuvers in 65 patients (5.0%, (95%CI: 3.8, 6.1%)). In multivariable analysis, age OR 1.02; 95%CI (1.00, 1.04); p = 0.01, male gender OR 0.53; 95%CI (0.31, 0.91); p = 0.02 and CA occurring at home OR 0.54; 95%CI (0.31, 0.92); p = 0.02 were significantly associated with the occurrence of a CPR-related injury. CPR-related injuries were not associated with the ICU survival OR 0.69; 95%CI (0.36, 1.33); p = 0.27.
Major traumatic injuries are common after cardiopulmonary resuscitation. Further studies are necessary to evaluate the interest of a systematic traumatic check-up in resuscitated OHCA patients in order to detect these injuries.
Background
Extracellular fluid volume (ECF) is independently associated with chronic kidney disease (CKD) progression and mortality in patients with CKD, but the prognostic value of the trajectory of ...ECF over time beyond that of baseline value is unknown.
Objectives
To characterize ECF trajectory and evaluate its association with the risks of end‐stage kidney disease (ESKD) and mortality.
Methods
From the prospective tricentric NephroTest cohort, we included 1588 patients with baseline measured glomerular filtration rate (mGFR) ≥15 mL min−1/1.73 m2 and ECF measurement. ECF and GFR were measured repeatedly using the distribution volume and clearance of 51Cr‐EDTA, respectively. ESKD and mortality were traced through record linkage with the national registries. Adjusted shared random‐effect joint models were used to analyse the association between the trajectory of ECF over time and the two competing outcomes.
Results
Patients were mean age 58.7 years, 66.7% men, mean mGFR of 43.6 ± 18.6 mL min−1/1.73 m2 and mean ECF of 16.1 ± 3.6 L. Over a median follow‐up of 5.3 IQR: 3.0;7.4 years, ECF increased by 136 95%CI 106;167 mL per year on average, whilst diuretic prescription and 24‐hour urinary sodium excretion remained stable. ESKD occurred in 324 (20.4%) patients, and 185 (11.6%) patients died before ESKD. A higher current value of ECF was associated with increased hazards of ESKD (adjusted hazard ratio aHR: 1.12 95%CI 1.06;1.18; P < 0.001 per 1 L increase in ECF), and death before ESKD (aHR: 1.10 95%CI 1.04;1.17; P = 0.002).
Conclusions
The current value of ECF was associated with the risks of ESKD and mortality, independent of multiple potential confounders, including kidney function decline. This highlights the need for a close monitoring and adjustment of treatment to avoid fluid overload in CKD patients.
Abstract Aim Hypoxic hepatitis (HH) may complicate the course of resuscitated out-of-hospital cardiac arrest (OHCA) patients admitted in intensive care unit (ICU). Aims of this study were to assess ...the prevalence of HH, and to describe the factors associated with HH occurrence and outcome. Methods We conducted an observational study over a 6-year period (2009–2014) in a cardiac arrest center. All non-traumatic OHCA patients admitted in the ICU after return of spontaneous circulation (ROSC) and who survived more than 24 h were included. HH was defined as an elevation of alanine aminotransferase over 20 times the upper limit of normal during the first 72 h after OHCA. Factors associated with HH and ICU mortality were picked up by multivariate logistic regression. Results Among the 632 OHCA patients included in the study, HH was observed in 72 patients (11.4% (95% CI: 9.0%, 14.1%)). In multivariate analysis, time from collapse to ROSC OR 1.02 per additional minute; 95% CI (1.00, 1.04); p = 0.01, male gender OR 0.53; 95% CI (0.29, 0.95); p = 0.03 and initial shockable rhythm OR 0.35; 95% CI (0.19, 0.65); p < 0.01 were associated with HH occurrence. After adjustment for confounding factors, HH was associated with ICU mortality OR 4.39; 95% CI (1.71, 11.26); p < 0.01 and this association persisted even if occurrence of a post-CA shock was considered in the statistical model OR 3.63; 95% CI (1.39, 9.48); p = 0.01. Conclusions HH is not a rare complication after OHCA. This complication is mainly triggered by the duration of resuscitation and is associated with increased ICU mortality.
Purpose
Tuberculous paradoxical reactions (PR) have been seldom studied in non-immunocompromised patients. We conducted a study to describe the incidence, clinical and biological features, treatment ...and outcome of PR in human immunodeficiency virus (HIV)-negative patients treated for extrapulmonary tuberculosis (TB) and to identify predictive factors of PR.
Methods
A single-center retrospective study was conducted in consecutive HIV-negative patients presenting with TB with at least one extrapulmonary manifestation who were hospitalized in an internal medicine department between 2000 and 2010.
Results
Seventy-six patients were enrolled in the study. Lymphadenitis was the most common extrapulmonary manifestation of tuberculosis among this patient population (72 %). PR occurred in 19 (25 %) patients, mostly involving the lymph nodes (68 %) and lung (16 %), but also the pericardium, pleura, bone, muscle and brain. Median time to PR onset after initiation of anti-TB regimen was 86 days (interquartile range 36–125). Treatment of PR consisted mainly of corticosteroids (47 % of patients) and needle aspiration of PR lymph nodes (31 %). Peripheral lymph node involvement (
p
= 0.009), lymphopenia (
p
= 0.03) and anemia (
p
= 0.002) at presentation were associated with PR occurrence. Outcome was favorable in all patients with PR but one; the latter suffered residual paraplegia.
Conclusions
Paradoxical reactions are frequent in the course of extrapulmonary TB treatment in HIV-negative patients but their outcome is excellent, except in some cases with central nervous system involvement.
Abstract Aim Low survival rate was previously described after cardiac arrest in cancer patients and may challenge the appropriateness of intensive care unit (ICU) admission after return of ...spontaneous circulation (ROSC). Objectives of this study were to report outcome and characteristics of cancer patients admitted to the ICU after cardiac arrest. Methods A retrospective chart review in seven medical ICUs in France, in 2002–2012. We studied consecutive patients with malignancies admitted after out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (IHCA). Results Of 133 included patients of whom 61% had solid tumors, 48 (36%) experienced OHCA and 85 (64%) IHCA. Cardiac arrest was related to the malignancy or its treatment in 47% of patients. Therapeutic hypothermia was used in 51 (41%) patients. The ICU mortality rate was 98/133 (74%). Main causes of ICU death were refractory shock or multiple organ failure ( n = 64, 48%) and neurological injury ( n = 27, 20%); 42 (32%) patients died in ICU after treatment-limitation decisions. Twenty-four (18%) patients were discharged alive from the hospital. Overall 6-month survival rate was 14% (18/133, 95% confidence interval, 8–21%). Survival rates at ICU discharge and after 6 months did not differ significantly across type of malignancy or between the OHCA and IHCA groups, and neither were they significantly different from those in matched controls who had cardiac arrest but no malignancy. Conclusions Even if low, the 6-month survival rate of 14% observed in cancer patients admitted to the ICU after cardiac arrest and ROSC may support the admission of these patients to the ICU and may warrant an initial full-code ICU management.
Hepatic granulomas Geri, G; Cacoub, P
La revue de medecine interne
32, Številka:
9
Journal Article
Recenzirano
Odprti dostop
Liver granulomas are histopathologically defined and associated with various liver and non-livers disorders. There are five main causes of liver granulomatosis: primary biliary cirrhosis, ...tuberculosis, sarcoidosis, B and C viral hepatitis, and drug related. In the other cases, not associated with an underlying systemic granulomatous disease, a systematic diagnostic approach should be used to identify less common etiologies. After a careful diagnostic work-up, a long-term follow-up of patients with undetermined liver granulomatosis is mandatory as it may be a presenting feature of liver lymphoma.
To assess the frequency and effectiveness of switching TNF blockers in spondyloarthritis, and the predisposing factors of this effectiveness.
This was a retrospective systematic monocentre study; ...inclusion criteria were definite spondyloarthritis (Amor's criteria) and introduction of a first TNF blocker after January 2004. The retention rate of the first and second TNF blocker (if applicable) was evaluated (Kaplan-Meier technique). Patients' characteristics were compared with regard to requirement for switching. Predisposing factors of retention of the second TNF blocker were analysed (log-rank, Cox).
A total of 222 patients started a first TNF blocker; 79% fulfilled the New York modified criteria, with increased CRP (75%) and median BASDAI of 50 (35-61). Mean follow up was 29±20 months (i.e. a total of 538 patient-years). By the end of follow-up, 72 patients (32%) had switched to a second TNF blocker. Patients who switched had more peripheral enthesitic symptoms (p=0.01) and a tendency for more peripheral involvement (p=0.06). Retention of the first and second TNF blocker was similar (p=0.32). No predictive factors were found for retention of the second TNF blocker; including no difference between TNF blockers and between reasons for stopping the first.
The effectiveness of switching TNF blocker in spondyloarthritis appears clinically relevant; no predictive factors of this effectiveness were evidenced.
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