Noninvasive ventilation during acute respiratory distress syndrome in patients with cancer: Trends in use and outcome.

PURPOSE: The objectives of our study were to describe the outcome of patients with malignancies treated for acute respiratory distress syndrome (ARDS) with noninvasive ventilation (NIV) and to evaluate factors associated with NIV failure. METHODS: Post hoc analysis of a multicenter database within 20 years was performed. All patients with malignancies and Berlin ARDS definition were included. Noninvasive ventilation use was defined as NIV lasting more than 1 hour, whereas failure was defined as a subsequent requirement of invasive ventilation. Conditional backward logistic regression analyses were conducted. RESULTS: A total of 1004 met the Berlin definition of ARDS. Noninvasive ventilation was used in 387 patients (38.6%) and NIV failure occurred in 71%, with an in-hospital mortality of 62.7%. Severity of ARDS defined by the partial pressure arterial oxygen and fraction of inspired oxygen ratio (odds ratio [OR], 2.20; 95% confidence interval [CI], 1.15-4.19), pulmonary infection (OR, 1.81; 95% CI, 1.08-3.03), and modified Sequential Organ Failure Assessment (SOFA) score (OR, 1.13; 95% CI, 1.06-1.21) were associated with NIV failure. Factors associated with hospital mortality were NIV failure (OR, 2.52; 95% CI, 1.56-4.07), severe ARDS as compared with mild ARDS (OR, 1.89; 95% CI, 1.05-1.19), and modified SOFA score (OR, 1.12; 95% CI, 1.05-1.19). CONCLUSION: Noninvasive ventilation failure in ARDS patients with malignancies is frequent and related to ARDS severity, SOFA score, and pulmonary infection-related ARDS. Noninvasive ventilation failure is associated with in-hospital mortality.

[Immediate allergy to oral corticosteroids]. / Allergie immédiate aux glucocorticoïdes de synthèse oraux.

INTRODUCTION: Corticosteroids are widely used for the management of many diseases because of anti-inflammatory and immunomodulatory properties. Sulfite intolerance is well known but immediate hypersensitivity to corticosteroids is rarer and must be reported. EXEGESIS: We report a case of a 38-year-old man, followed since 1986 for asthma with sulfite intolerance. He twice developed urticaria after ingesting betalactam antibiotics associated with corticosteroids of the group A, according to the Matura and Goossens's classification. The allergy inquiry confirmed not only a beta-lactame allergy but also in corticosteroids of the group A. Intradermal reactions with methylprednisolone and hydrocortisone were positive at 7 mm for methylprednisolone on 1/1000 dilution and at 4 mm for hydrocortisone on 1/10 dilution. Thus immediate allergy to corticosteroids was confirmed. But those skin tests were negative for corticosteroids of group B and C. In order to propose an alternative therapy for acute asthma, an intravenous injection of 4 mg of betamethasone was performed without inducing immediate and delayed allergic reactions. CONCLUSION: Corticosteroid allergy is rare and can be fatal. Many asthmatic or acetylsalicylic acid intolerant patients may be concerned. The diagnostic of corticosteroid allergy have to be confirmed by clinical history and skin tests of the different groups to try to identify one or more allergens and to propose a alternative treatment if necessary.

[Duodenocaval fistula: an unusual form of peptic ulcer revelation]. / Fistule duodénocave: mode de révélation inhabituel d'un ulcère duodénal.

The duodenocaval fistula is exceptional. We report the case of a 44-year-old patient with duodenocaval fistula. The patient had no history of peptic ulcer disease. The clinical feature was firstly a septic shock and then an haemorrhagic shock. Only laparotomy confirmed the diagnosis. The treatment was a surgical one with a rapid improvement. The prognosis depends on surgical experience and remains serious.

Prognosis of neutropenic patients admitted to the intensive care unit.

PURPOSE: The prognosis of critically ill cancer patients has improved recently. Controversies remain as regard to the specific prognosis impact of neutropenia in critically ill cancer patients. The primary objective of this study was to assess hospital outcome of critically ill neutropenic cancer patients admitted into the ICU. The secondary objective was to assess risk factors for unfavorable outcome in this population of patients and specific impact of neutropenia. METHODS: We performed a post hoc analysis of a prospectively collected database. The study was carried out in 17 university or university-affiliated centers in France and Belgium. Neutropenia was defined as a neutrophil count lower than 500/mm(3). RESULTS: Among the 1,011 patients admitted into the ICU during the study period 289 were neutropenic at the time of admission. Overall, 131 patients died during their hospital stay (hospital mortality 45.3 %). Four variables were associated with a poor outcome, namely allogeneic transplantation (OR 3.83; 95 % CI 1.75-8.35), need for mechanical ventilation (MV) (OR 6.57; 95 % CI 3.51-12.32), microbiological documentation (OR 2.33; CI 1.27-4.26), and need for renal replacement therapy (OR 2.77; 95 % CI 1.34-5.74). Two variables were associated with hospital survival, namely age younger than 70 (OR 0.22; 95 % CI 0.1-0.52) and neutropenic enterocolitis (OR 0.37; 95 % CI 0.15-0.9). A case-control analysis was also performed with patients of the initial database; after adjustment, neutropenia was not associated with hospital mortality (OR 1.27; 95 % CI 0.86-1.89). CONCLUSION: Hospital survival was closely associated with younger age and neutropenic enterocolitis. Conversely, need for conventional MV, for renal replacement therapy, and allogeneic hematopoietic stem cell transplantation (HSCT) were associated with poor outcome.

[Allergy to squid and acari in a child]. / Allergie au calmar et aux acariens chez l'enfant.

UNLABELLED: Anaphylactic reactions after consumption of squid by patients sensitized to house dust mites have been reported several times. CASE REPORT: A child allergic to dust mites developed an angioneurotic edema after eating squid. An immunoallergological assessment, including the prick test, labial test and IgE RAST revealed an allergy associated to both dust mites and squid. CONCLUSIONS: In light of the potential seriousness of anaphylactic reactions, parents of children allergic to dust mites and these children should be made aware of the increased risk of allergies to squid that they may face.

[Needle aspiration in paradoxical hypertrophy of tuberculous lymphadenitis]. / Efficacité de l'aspiration à l'aiguille au cours d'un cas d'hypertrophie paradoxale d'une lymphadénite tuberculeuse.

INTRODUCTION: Paradoxical hypertrophy is frequent in case of peripheral lymph node tuberculosis. Its management remains controversial. CASE STUDY: We report a case of susclavicular and anterior cervical lymph nodes tuberculosis complicated by paradoxical hypertrophy after 4 months of treatment in a 59-year-old woman. The lymph node was not compressive but was limiting the cervical mobilisation. The caseum was sucking three times with a fine needle. Thereafter we performed an isoniazid injection each 24 hours for three days at three different lymph node sites. Antituberculous treatment was reinitiated for 10 months at all and lymph nodes completely disappeared without functional sequels. CONCLUSION: Paradoxical hypertrophy is a frequent complication of peripheral lymph node tuberculosis. Caseum suction of the paradoxical hypertrophy with a fine needle may constitute an alternative treatment of surgery.

Relationship between tracheotomy and ventilator-associated pneumonia: a case control study.

The aim of the present study was to determine the relationship between tracheotomy and ventilator-associated pneumonia (VAP). The study used a retrospective case-control study design based on prospective data. All nontrauma immunocompetent patients, intubated and ventilated for >7 days, were eligible for inclusion in the study. A diagnosis of VAP was based on clinical, radiographical and microbiological criteria. Four matching criteria were used, including duration of mechanical ventilation (MV). The indication and timing of tracheotomy were at the discretion of attending physicians. Univariate and multivariate analyses were performed to determine risk factors for VAP in cases (patients with tracheotomy) and controls (patients without tracheotomy). In total, 1,402 patients were eligible for inclusion. Surgical tracheotomy was performed in 226 (16%) patients and matching was successful for 177 (78%). The rate of VAP (22 versus 14 VAP episodes.1,000 MV-days(-1)) was significantly higher in controls than in cases. The rate of VAP after tracheotomy in cases, or after the corresponding day of MV in controls, was also significantly higher in control than in case patients (9.2 versus 4.8 VAP episodes.1,000 MV-days(-1)). In multivariate analysis, neurological failure (odds ratio (95% confidence interval) 2.7 (1.3-5)), antibiotic treatment (2.1 (1.1-3.2)) and tracheotomy (0.18 (0.1-0.3)) were associated with VAP. In summary, the present study demonstrates that tracheotomy is independently associated with decreased risk for ventilator-associated pneumonia.