Real-life efficacy of immunotherapy for Sézary syndrome: a multicenter observational cohort study.

Background: Sézary syndrome is an extremely rare and fatal cutaneous T-cell lymphoma (CTCL). Mogamulizumab, an anti-CCR4 monoclonal antibody, has recently been associated with increased progression-free survival in a randomized clinical trial in CTCL. We aimed to evaluate OS and prognostic factors in Sézary syndrome, including treatment with mogamulizumab, in a real-life setting. Methods: Data from patients with Sézary (ISCL/EORTC stage IV) and pre-Sézary (stage IIIB) syndrome diagnosed from 2000 to 2020 were obtained from 24 centers in Europe. Age, disease stage, plasma lactate dehydrogenases levels, blood eosinophilia at diagnosis, large-cell transformation and treatment received were analyzed in a multivariable Cox proportional hazard ratio model. This study has been registered in ClinicalTrials (SURPASSe01 study: NCT05206045). Findings: Three hundred and thirty-nine patients were included (58% men, median age at diagnosis of 70 years, Q1-Q3, 61-79): 33 pre-Sézary (9.7% of 339), 296 Sézary syndrome (87.3%), of whom 10 (2.9%) had large-cell transformation. One hundred and ten patients received mogamulizumab. Median follow-up was 58 months (95% confidence interval [CI], 53-68). OS was 46.5% (95% CI, 40.6%-53.3%) at 5 years. Multivariable analysis showed that age ≥ 80 versus <50 (HR: 4.9, 95% CI, 2.1-11.2, p = 0.001), and large-cell transformation (HR: 2.8, 95% CI, 1.6-5.1, p = 0.001) were independent and significant factors associated with reduced OS. Mogamulizumab treatment was significantly associated with decreased mortality (HR: 0.34, 95% CI, 0.15-0.80, p = 0.013). Interpretation: Treatment with mogamulizumab was significantly and independently associated with decreased mortality in Sézary syndrome. Funding: French Society of Dermatology, Swiss National Science Foundation (IZLIZ3_200253/1) and SKINTEGRITY.CH collaborative research program.

[Chronology of the ISO 9001:2015 certification and satisfaction survey in the multidisciplinary Clinical Investigation Center (CIC) of the historic Saint-Louis Hospital during the COVID-19 pandemic]. / Chronologie de la certification ISO 9001:2015 et enquête de satisfaction au sein du centre d'investigations cliniques plurithématique (CIC-P) de l'historique hôpital Saint-Louis en période de pandémie du COVID-19.

The main objectives of multidisciplinary clinical investigation center (CIC-P) are to facilitate the availability of new drugs for patients, to enhance the visibility and attractiveness of French clinical research, to improve the quality of early phase trials, and to enhance the value of academic research by evaluating molecules in rare diseases. Since 2017, the CIC-P has been committed to a quality approach process, launching in 2018 its first satisfaction survey on patient care and clinical trial management of all its employees. A second satisfaction survey targeted by profession type was to be launched in 2020, in view of the requirements of the ISO 9001:2015 standard, but the process was interrupted following the coronavirus diseases 2019 (COVID-19) pandemic. The successful reorganization of the CIC-P activity during the first containment of the COVID-19 pandemic was driven by the implementation of a quality management system that promotes continuous improvement through the organization and involvement of all the staff. This voluntary and participative approach motivated the CIC-P to apply for the organizational sesame. The ISO 9001:2015 certification of CIC-P aims at increasing its performance, to satisfying its customers and to fully integrate its activities in a continuous improvement process, according to the requirements of this international standard, through the deployment of quality tools such as The Deming wheel (PDCA), an indispensable tool for transformation and reorganization; the analysis of the environment by the strengths, weakness, opportunities, threats (SWOT) analysis tool; the analysis and management of risks by the FMEA method, and all with performance indicators (SMART) and precise objectives at each stage of a project/process. The implementation of satisfaction questionnaires remains the essential tool for evaluating the expectations and needs of interested parties, but also for improving the quality of CIC-P activities and services. All these tools put in place have allowed us to continuously improve the means of production and to constantly improve our organization.

Efficacy of vancomycin lock therapy for totally implantable venous access port-related infection due to coagulase-negative staphylococci in 100 patients with cancer.

OBJECTIVES: Data on the efficacy of vancomycin catheter lock therapy (VLT) for conservative treatment of totally implantable venous access port-related infections (TIVAP-RI) due to CoNS are scarce. The aim of this study was to evaluate the effectiveness of VLT in the treatment of TIVAP-RI due to CoNS in cancer patients. METHODS: This prospective, observational, multicentre study included adults with cancer treated with VLT for a TIVAP-RI due to CoNS. The primary endpoint was the success of VLT, defined as no TIVAP removal nor TIVAP-RI recurrence within 3 months after initiation of VLT. The secondary endpoint was 3 month mortality. Risk factors for VLT failure were also analysed. RESULTS: One hundred patients were included [men 53%, median age 63 years (IQR 53-72)]. Median duration of VLT was 12 days (IQR 9-14). Systemic antibiotic therapy was administered in 87 patients. VLT was successful in 44 patients. TIVAP could be reused after VLT in 51 patients. Recurrence of infection after completion of VLT occurred in 33 patients, among which TIVAP was removed in 27. Intermittent VLT (antibiotic solution left in place in the TIVAP lumen part of the time) was identified as a risk factor for TIVAP-RI recurrence. At 3 months, 26 deaths were reported; 1 (4%) was related to TIVAP-RI. CONCLUSIONS: At 3 months, success of VLT for TIVAP-RI due to CoNS was low. However, removing TIVAP was avoided in nearly half the patients. Continuous locks should be preferred to intermittent locks. Identifying factors of success is essential to select patients who may benefit from VLT.

Effectiveness of a multidisciplinary care program for the management of venous thromboembolism in cancer patients: a pilot study.

INTRODUCTION: Treatment of Venous thromboembolism (VTE) in cancer patients is challenging due to higher risk of VTE recurrence or bleeding under anticoagulants. We assessed the effectiveness of a dedicated "Allo-Thrombosis Cancer" multidisciplinary care program (AlloTC-MCP) that incorporated individualized care, regular follow-ups, telephone counselling, and a patient education program. METHODS AND MATERIALS: From September 2017 to October 2019, 100 consecutive cancer patients with new VTE onset were enrolled in this observational single-center prospective pilot study and received standard (control group, n = first 50 patients enrolled) or AlloTC-MCP care (n = next 50 patients enrolled) over a 6-month VTE treatment follow-up period. Primary end-point was the percentage of adherence to the International Clinical Practice Guidelines (ITAC-CPGs) at 6 (M6) month follow-up. RESULTS: Among the 100 patients with different cancer types (22% genitourinary, 19% breast, 16% gastrointestinal, 15% lymphoma, 11% lung and 17% others), 51 patients (61%) had metastatic disease and 31 (31%) received chemotherapy alone. Main baseline cancer and VTE clinical characteristics did not differ between the 2 groups. Adherence rates to ITAC-CPGs was significantly higher in the AlloTC-MCP group (100% (M0), 72% (M3) and 68% (M6)) compared with the control group (84% (M0), 8% (M3) and 16% (M6)). Quality of Life (QoL) was significantly improved in the AlloTC-MCP group 6 months after inclusion. CONCLUSION: The "AlloTC-MCP" was associated with improved adherence to ITAC-CPGs and merits further expansion.

Response to Lithium in Patients with Bipolar Disorder: What are Psychiatrists' Experiences and Practices Compared to Literature Review?

BACKGROUND: This study aims at characterizing French psychiatrists' opinions regarding definition criteria and factors associated with lithium prophylactic response in patients with bipolar disorders. METHODS: After a literature review, an online survey targeted French psychiatrists in 2016. RESULTS: Literature review showed inconsistencies in reported definition criteria and clinical predictors of lithium prophylactic response. A total of 104 psychiatrists, mostly working in hospitals, completed the survey. The inconsistencies regarding definition criteria and predictors of lithium response were confirmed. Five factors were commonly reported by psychiatrists as positively associated with successful response (family history of lithium response and of bipolar I disorder, and lithium efficacy in acute mood phases treatment) or with an unsuccessful response (rapid cycling and alcohol misuse). DISCUSSION: The divergence in psychiatrists' opinions surely plays a major role in the variability of lithium prescriptions among psychiatrists. Currently, the large variations in response definitions, and in study designs used to quantify each factor's effect, preclude synthesizing the findings. A standardization of response measures is needed to explore factors that influence the prophylactic lithium efficacy.

Dyspnoea in patients receiving noninvasive ventilation for acute respiratory failure: prevalence, risk factors and prognostic impact: A prospective observational study.

Dyspnoea is a frequent and intense symptom in intubated patients, but little attention has been paid to dyspnoea during noninvasive mechanical ventilation in the intensive care unit (ICU).The objectives of this study were to quantify the prevalence, intensity and prognostic impact of dyspnoea in patients receiving noninvasive ventilation (NIV) for acute respiratory failure (ARF) based on secondary analysis of a prospective observational cohort study in patients who received ventilatory support for ARF in 54 ICUs in France and Belgium. Dyspnoea was measured by a modified Borg scale.Among the 426 patients included, the median (interquartile range) dyspnoea score was 4 (3-5) on admission and 3 (2-4) after the first NIV session (p=0.001). Dyspnoea intensity ≥4 after the first NIV session was associated with the Sequential Organ Failure Assessment Score (odds ratio (OR) 1.12, p=0.001), respiratory rate (OR 1.03, p=0.032), anxiety (OR 1.92, p=0.006), leaks (OR 2.5, p=0.002) and arterial carbon dioxide tension (OR 0.98, p=0.025). Dyspnoea intensity ≥4 was independently associated with NIV failure (OR 2.41, p=0.001) and mortality (OR 2.11, p=0.009), but not with higher post-ICU burden and altered quality of life.Dyspnoea is frequent and intense in patients receiving NIV for ARF and is associated with a higher risk of NIV failure and poorer outcome.

Clinical characteristics, risk factors, and outcome of tuberculosis in kidney transplant recipients: A multicentric case-control study in a low-endemic area.

OBJECTIVES: Tuberculosis (TB) is a rare but life-threatening infection after solid organ transplant. The present study was undertaken to assess the clinical features, risk factors, and outcome of TB after kidney transplantation in a low-prevalence area. METHODS: We conducted a retrospective study, describing all kidney transplant recipients diagnosed with TB between 2005 and 2015 in 3 French centers. For each TB case, 2 controls without TB were identified and matched by center, age, transplant date, and birth country. Risk factors associated with TB were identified and survival estimated. RESULTS: Thirty-two cases and 64 control patients were included among 3974 transplantations. The prevalence of TB was 0.83%. Median age at the time of diagnosis was 64 years; 75% were born in a high TB prevalence country, but only 3 had received isoniazid prophylaxis for latent TB infection. TB occurred at a median of 22 months after transplantation. On diagnosis, 66% had disseminated infection. Median duration of treatment was 9 months. Immunosuppressive therapy changes were necessary in all patients because of drug-drug interactions. Among cases, 5 deaths occurred during follow-up (median duration: 41 months), one directly related with TB. Survival was significantly lower in transplant recipients with TB, as compared to controls (P = .001). No predictive factors of tuberculosis after transplantation were statistically significant in univariate analysis. CONCLUSION: TB in kidney transplant recipients is a rare and late event, but is associated with significantly reduced survival. Our results emphasize the need for systematic screening for LTBI, followed by IPT in high-risk patients.

Clinicians' Perception and Experience of Organ Donation From Brain-Dead Patients.

OBJECTIVE: ICU clinicians are primarily involved in organ donation after brain death of ICU patients. Their perceptions of organ donation may affect outcomes. Our objective was to describe ICU clinician's perceptions and experience of organ donation. DESIGN AND SETTING: Cross-sectional study among physicians and nurses (90 ICUs in France). We used factorial correspondence analysis to describe categories of clinicians regarding their perceptions and experience of organ donation. Factors associated with a positive (motivating) or negative (stressful) experiences were studied using multivariate logistic regression. PARTICIPANTS: Physicians and nurses. MEASUREMENTS AND MAIN RESULTS: Three thousand three hundred twenty-five clinicians working in 77 ICUs returned questionnaires. Professionals who experienced organ donation as motivating were younger (odds ratio, 0.41; 95% CI, 0.32-0.53; p < 0.001), more often potential organ donors (odds ratio, 1.92; 95% CI, 1.56-2.35; p < 0.001), less likely to describe inconsistency (odds ratio, 0.43; 95% CI, 0.23-0.8) or complexity (odds ratio, 0.55; 95% CI, 0.45-0.67) of their feelings versus their professional activity, less likely to report that organ donation was not a priority in their ICU (odds ratio, 0.68; 95% CI, 0.55-0.84), and more likely to have participated in meetings of transplant coordinators with relatives (odds ratio, 1.71; 95% CI, 1.37-2.14; p < 0.001). Professionals who felt organ donation was stressful were older (odds ratio, 1.84; 95% CI, 1.34-2.54; p < 0.001), less often physicians (odds ratio, 0.58; 95% CI, 0.44-0.77; p < 0.001), more likely to describe shift from curative care to organ donation as emotionally complex (odds ratio, 1.83; 95% CI, 1.52-2.21; p < 0.001), care of relatives of brain-dead patients as complex (odds ratio, 1.59; 95% CI, 1.32-1.93; p < 0.001), and inconsistency and complexity of personal feelings about organ donation versus professional activity (odds ratio, 3.25; 95% CI, 1.92-5.53; p < 0.001), and more likely to have little experience with caring for potential organ donors (odds ratio, 1.49; 95% CI, 1.09-2.04). CONCLUSIONS: Significant differences exist among ICU clinician's perceptions of organ donation. Whether these differences affect family experience and consent rates deserves investigation.

Targeted temperature management after intraoperative cardiac arrest: a multicenter retrospective study.

PURPOSE: Few outcome data are available about temperature management after intraoperative cardiac arrest (IOCA). We describe targeted temperature management (TTM) (32-34 °C) modalities, adverse events, and association with 1-year functional outcome in patients with IOCA. METHODS: Patients admitted to 11 ICUs after IOCA in 2008-2013 were studied retrospectively. The main outcome measure was 1-year functional outcome. RESULTS: Of the 101 patients [35 women and 66 men; median age, 62 years (interquartile range, 42-72)], 68 (67.3%) were ASA PS I to III and 57 (56.4%) had emergent surgery. First recorded rhythms were asystole in 44 (43.6%) patients, pulseless electrical activity in 36 (35.6%), and ventricular fibrillation/tachycardia in 20 (19.8%). Median times from collapse to cardiopulmonary resuscitation and return of spontaneous circulation (ROSC) were 0 min (0-0) and 10 min (4-20), respectively. The 30 (29.7%) patients who received TTM had an increased risk of infection (P = 0.005) but not of arrhythmia, bleeding, or metabolic/electrolyte disorders. By multivariate analysis, one or more defibrillation before ROSC was positively associated with a favorable functional outcome at 1-year (OR 3.06, 95% CI 1.05-8.95, P = 0.04) and emergency surgery was negatively associated with 1-year favorable functional outcome (OR 0.36; 95% CI 0.14-0.95, P = 0.038). TTM use was not independently associated with 1-year favorable outcome (OR 0.82; 95% CI 0.27-2.46, P = 0.72). CONCLUSIONS: TTM was used in less than one-third of patients after IOCA. TTM was associated with infection but not with bleeding or coronary events in this setting. TTM did not independently predict 1-year favorable functional outcome after IOCA in this study.

Age-at-onset subsets of bipolar I disorders: A critical insight into admixture analyses.

Gaussian mixture analysis is frequently used to model the age-at-onset (AAO) in bipolar I disorder and identify homogeneous subsets of patients. This study aimed to examine whether, using admixture analysis of AAO, cross-sectional designs (which cause right truncation), unreliable diagnosis for individuals younger than 10 years old (which causes left truncation) and the selection criterion used for admixture analysis impact the number of identified subsets. A simulation study was performed. Different criteria - the likelihood ratio test (LRT), the Akaike information criterion (AIC), and the Bayesian information criterion (BIC) - were compared using no, left and/or right truncation simulated data. The error rate of each criterion (percentage of erroneous number of detected subsets) was estimated. An application to two real databases, including 2,876 and 1,393 patients, is provided. Without data truncation and regardless of the distribution of AAO, the LRT and the AIC had much higher error rates (12% and 33%, respectively) than the BIC (1%). For a homogeneous population, the error rate increased with the introduction of left truncation. This study shows that the number of subsets identified using admixture analysis may depend on the sample size, the selection criterion, and the study design.

Reducing Radiation Dose at Chest CT: Comparison Among Model-based Type Iterative Reconstruction, Hybrid Iterative Reconstruction, and Filtered Back Projection.

RATIONALE AND OBJECTIVES: The study aimed to evaluate the performances of two iterative reconstruction (IR) algorithms and of filtered back projection (FBP) when using reduced-dose chest computed tomography (RDCT) compared to standard-of-care CT. MATERIALS AND METHODS: An institutional review board approval was obtained. Thirty-six patients with hematologic malignancies referred for a control chest CT of a known lung disease were prospectively enrolled. Patients underwent standard-of-care scan reconstructed with hybrid IR, followed by an RDCT reconstructed with FBP, hybrid IR, and iterative model reconstruction. Objective and subjective quality measurements, lesion detectability, and evolution assessment on RDCT were recorded. RESULTS: For RDCT, the CTDIvol (volumetric computed tomography dose index) was 0.43 mGy⋅cm for all patients, and the median [interquartile range] effective dose was 0.22 mSv [0.22-0.24]; corresponding measurements for standard-of-care scan were 3.4 mGy [3.1-3.9] and 1.8 mSv [1.6-2.0]. Noise significantly decreased from FBP to hybrid IR and from hybrid IR to iterative model reconstruction on RDCT, whereas lesion conspicuity and diagnostic confidence increased. Accurate evolution assessment was obtained in all cases with IR. Emphysema identification was higher with iterative model reconstruction. CONCLUSION: Although iterative model reconstruction offered better diagnostic confidence and emphysema detection, both IR algorithms allowed an accurate evolution assessment with an effective dose of 0.22 mSv.

Squamous Cell Carcinoma Following Photodynamic Therapy for Cutaneous Bowen's Disease in a Series of 105 Patients.

Photodynamic therapy (PDT) is an alternative to surgery for Bowen's disease. This monocentric retrospective study included 105 patients with Bowen's disease, treated with PDT between 2007 and 2013, who received a total of 151 different PDT fields. Comparison of immunocompromised and non-immunocompromised patients revealed that the former often had a previous history of squamous cell carcinoma (SCC; p = 0.004) and received more PDT fields (p = 0.007) than the latter. At least one SCC occurred post-PDT in 16 out of 105 patients in a PDT field. However, many of the patients were at risk of SCC and the possibility that the lesion did not have a mixed histology at baseline, but might simply be a transformation of non-PDT-responsive Bowen's disease, cannot be excluded. Although it is rare, patients should be closely monitored for SCC post-PDT.

Bladder Cancer in HIV-infected Adults: An Emerging Issue? Case-Reports and Systematic Review.

OBJECTIVES: Non-AIDS-related malignancies now represent a frequent cause of death among HIV-infected patients. Albeit bladder cancer is one of the most common malignancies worldwide, it has been rarely reported among HIV-infected patients. We wished to assess the prevalence and characteristics of bladder cancer in HIV-infected patients. METHODS: We conducted a single center retrospective study from 1998 to 2013 in a university hospital in Paris. Cases of bladder cancer among HIV-infected patients were identified using the electronic records of the hospital database and of the HIV-infected cohort. Patient characteristics and outcomes were retrieved from patients charts. A systematic review of published cases of bladder cancers in patients with HIV-infection was also performed. RESULTS: During the study period we identified 15 HIV-infected patients (0.2% of the cohort) with a bladder cancer. Patients were mostly men (73%) and smokers (67%), with a median age of 56 years at cancer diagnosis. Bladder cancer was diagnosed a median of 14 years after HIV-infection. Most patients were on ART (86%) with median current and nadir CD4 cell counts of 506 and 195 cells/mm3, respectively. Haematuria (73%) was the most frequent presenting symptom and HPV-associated lesions were seen in 6/10 (60%) patients. Histopathology showed transitional cell carcinoma in 80% and a high proportion of tumors with muscle invasion (47%) and high histologic grade (73%). One-year survival rate was 74.6%. The systematic review identified 13 additional cases of urothelial bladder cancers which shared similar features. CONCLUSIONS: Bladder cancers in HIV-infected patients remain rare but may occur in relatively young patients with a low nadir CD4 cell count, have aggressive pathological features and can be fatal.

Outcomes in critically ill patients with systemic rheumatic disease: a multicenter study.

BACKGROUND: Patients with systemic rheumatic diseases (SRDs) may require ICU management for SRD exacerbation or treatment-related infections or toxicities. METHODS: This was an observational study at 10 university-affiliated ICUs in France. Consecutive patients with SRDs were included. Determinants of ICU mortality were identified through multivariable logistic analysis. RESULTS: Three hundred sixty-three patients (65.3% women; median age, 59 years [interquartile range, 42-70 years]) accounted for 381 admissions. Connective tissue disease (primarily systemic lupus erythematosus) accounted for 66.1% of SRDs and systemic vasculitides for 26.2% (chiefly antineutrophil cytoplasm antibodies-associated vasculitides). SRDs were newly diagnosed in 43 cases (11.3%). Direct admission to the ICU occurred in 143 cases (37.9%). Reasons for ICU admissions were infection (39.9%), SRD exacerbation (34.4%), toxicity (5.8%), or miscellaneous (19.9%). Respiratory involvement was the leading cause of admission (56.8%), followed by shock (41.5%) and acute kidney injury (42.2%). Median Sequential Organ Failure Assessment (SOFA) score on day 1 was 5 (3-8). Mechanical ventilation was required in 57% of cases, vasopressors in 33.9%, and renal replacement therapy in 28.1%. ICU mortality rate was 21.0% (80 deaths). Factors associated with ICU mortality were shock (OR, 3.77; 95% CI, 1.93-7.36), SOFA score at day 1 (OR, 1.19; 95% CI, 1.10-1.30), and direct admission (OR, 0.52; 95% CI, 0.28-0.97). Neither comorbidities nor SRD characteristics were associated with survival. CONCLUSIONS: In patients with SRDs, critical care management is mostly needed only in patients with a previously known SRD; however, diagnosis can be made in the ICU for 12% of patients. Infection and SRD exacerbation account for more than two-thirds of these situations, both targeting chiefly the lungs. Direct admission to the ICU may improve outcomes.

Bladder cancer in HIV-infected adults: an emerging concern?

INTRODUCTION: As HIV-infected patients get older more non-AIDS-related malignancies are to be seen. Cancer now represents almost one third of all causes of deaths among HIV-infected patients (1). Albeit bladder cancer is one of the most common malignancy worldwide (2), only 13 cases of bladder cancer in HIV-infected patients have been reported in the literature so far (3). MATERIALS AND METHODS: We conducted a monocentric study in our hospital. We selected all patients who were previously admitted (from 1998 to 2013) in our hospital with diagnoses of HIV and bladder cancer. The objective was to assess the prevalence and characteristics of bladder cancers in HIV-infected patients in our hospital. RESULTS: Based on our administrative HIV database (6353 patients), we found 15 patients (0.2%) with a bladder cancer. Patients' characteristics are presented in Table 1. Patients were mostly men and heavy smokers. Their median nadir CD4 cell count was below 200 and most had a diagnosis of AIDS. A median time of 14 years was observed in those patients, between the diagnosis of HIV-infection and the occurrence of bladder cancer, although in patients much younger (median age 56) than those developing bladder cancer without HIV infection (71.1 years) (4). Haematuria was the most frequent diagnosis circumstance in HIV-infected patients who had relatively preserved immune function on highly active antiretroviral therapy (HAART). Histopathology showed relatively advanced cancers at diagnosis with a high percentage of non transitional cell carcinoma (TCC) tumor and of TCC with squamous differentiation, suggesting a potential role for human papilloma virus (HPV) co-infection. Death rate was high in this population. CONCLUSIONS: Bladder cancers in HIV-infected patients remain rare but occur in relatively young HIV-infected patients with a low CD4 nadir, presenting with haematuria, most of them being smokers, and have aggressive pathological features that are associated with severe outcomes.

Predictors of functional outcome after intraoperative cardiac arrest.

BACKGROUND: Few outcome data are available about intraoperative cardiac arrest (IOCA). The authors studied 90-day functional outcomes and their determinants in patients admitted to the intensive care unit after IOCA. METHODS: Patients admitted to 11 intensive care units in a period of 2000-2013 were studied retrospectively. The main outcome measure was a day-90 Cerebral Performance Category score of 1 or 2. RESULTS: Of the 140 patients (61 women and 79 men; median age, 60 yr [interquartile range, 46 to 70]), 131 patients (93.6%) had general anesthesia, 80 patients (57.1%) had emergent surgery, and 73 patients (52.1%) had IOCA during surgery. First recorded rhythms were asystole in 73 patients (52.1%), pulseless electrical activity in 44 patients (31.4%), and ventricular fibrillation/ventricular tachycardia in 23 patients (16.4%). Median times from collapse to cardiopulmonary resuscitation and return of spontaneous circulation were 0 min (0 to 0) and 10 min (5 to 20), respectively. Postcardiac arrest shock was identified in 114 patients (81.4%). Main causes of IOCA were preoperative complications (n = 46, 32.9%), complications of anesthesia (n = 39, 27.9%), and complications of surgical procedures (n = 36, 25.7%). On day 90, 63 patients (45.3%) were alive with Cerebral Performance Category score 1/2. Independent predictors of day-90 Cerebral Performance Category score 1/2 were day-1 Logistic Organ Dysfunction score (odds ratio, 0.78 per point; 95% CI, 0.71 to 0.87; P = 0.0001), ventricular fibrillation/tachycardia as first recorded rhythm (odds ratio, 4.78; 95% CI, 1.38 to 16.53; P = 0.013), and no epinephrine therapy during postcardiac arrest syndrome (odds ratio, 3.14; 95% CI, 1.29 to 7.65; P = 0.012). CONCLUSIONS: By day 90, 45% of IOCA survivors had good functional outcomes. The main outcome predictors were directly related to IOCA occurrence and postcardiac arrest syndrome; they suggest that the intensive care unit management of postcardiac arrest syndrome may be amenable to improvement.

Assessment of cerebral blood flow changes in nonconvulsive status epilepticus in comatose patients: a pathophysiological transcranial Doppler study.

PURPOSE: We assessed the accuracy of transcranial Doppler (TCD) in helping to diagnose nonconvulsive status epilepticus (NCSE) in comatose patients admitted to the intensive care unit (ICU) for acute neurological disorders at high risk for NCSE. METHODS: A 2-year prospective observational study in 38 consecutive patients requiring continuous electroencephalography (EEG) monitoring and intracranial pressure monitoring with TCD. RESULTS: Of the 38 patients, 10 (26.3%) had NCSE by continuous EEG monitoring. Bilateral mean and maximal systolic and diastolic TCD velocities were significantly different between patients with and those without NCSE. Areas under the receiver-operating characteristic (ROC) curves of mean and maximal systolic velocities by TCD were 0.82 (95% CI, 0.64-1.00) and 0.79 (95% CI, 0.62-0.95) with cutoffs of 95 cm/s and 105 cm/s, respectively. Areas under the ROC curves of mean and maximal diastolic velocities were 0.76 (95% CI, 0.56-0.95) and 0.78 (95% CI, 0.60-0.96) with cutoffs of 31 cm/s and 40 cm/s, respectively. For none of the velocity parameters did the areas under the ROC curves differ significantly between the left and right sides. The best performance was obtained using mean systolic (SV) and a cutoff of 95 cm/s, which yielded a positive likelihood ratio of 3.8 and a negative likelihood ratio of 0.25. CONCLUSION: Our preliminary results showed a significant association between increased TCD velocities and NCSE in comatose patients. However, the likelihood ratios suggested a limited role for TCD in helping to diagnose seizure activity. Further studies with larger samples of NCSE patients are warranted to determine the exact contribution of TCD for NCSE detection in comatose ICU patients.