[Management of thrombotic thrombocytopenic purpura in two French centers: A series of 27 patients]. / Prise en charge du purpura thrombotique thrombopénique dans deux centres français : à partir de 27 patients.

INTRODUCTION: Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy due to platelet microthrombosis involved in multiple systems associated with multiple organ dysfunctions and often severe disease course. METHODS: In order to enhance the understanding of TTP, the clinical features, laboratory characteristics, treatment and outcome of 27 patients with TTP were retrospectively analyzed and investigated in two centres (Annecy and Grenoble). RESULTS: All the 27 patients presented with haemolytic anemia and decreased platelet counts. Eight patients had fever. Thirteen patients had kidney involvement including proteinuria and renal function abnormalities. Eighteen patients had neurological manifestations. Association of the 5 characteristic features of TTP was rarely found (11%) which could lead to diagnosis delay. The von Willebrand factor-cleaving protease (ADAMTS13) activity was less than 10% in all patients. At the same time, plasma ADAMTS13 inhibitors were detected in 20 patients out of the 27. After treatment with plasma exchange, glucocorticoid and rituximab, 23 patients (85%) achieved complete remission. Four patients died, in which two cases were secondary to late diagnosis. CONCLUSION: TTP is a thrombotic microangiopathy often associated with multiple organ dysfunctions. Salvage therapy, based on some studies experiences and discussed with the Reference Center, could help getting answers in most severe cases. Awareness of physicians is an important step to further limit any delay in medical care, and to further improve the prognosis of patients with TTP.

[Cerebral abscess during a severe form of Salmonella typhimurium bacteremia in an immunocompetent patient]. / Abcès cérébraux au cours d'une forme sévère de bactériémie à Salmonella typhimurium chez un sujet immunocompétent.

BACKGROUND: Bacteremia rarely occurs in non-typhoid salmonella infections and the development of a brain abscess is exceptional. CASE REPORT: An immunocompetent patient developed severe Salmonella typhimurium bacteremia leading to septic shock and acute respiratory distress and acute renal failure. A brain abscess, which was not present on the initial brain tomodensitometry, developed and totally regressed after antibiotic therapy. DISCUSSION: We were unable to identify and factor favoring the development of salmonella bacteremia in this patient. There were no cerebral lesions on the initial brain tomodensitometry considered to be normal. To our knowledge, this is the first report of Salmonella typhimurium brain abscess in an immunocompetent subject.

Prone position in mechanically ventilated patients with severe acute respiratory failure.

The purpose of this study was to characterize changes in oxygenation, expressed as PaO2/F(I)O2, when patients with severe acute respiratory failure (PaO2/F(I)O2 < 150), unrelated to left ventricular failure to atelectasis, were turned to and from a supine to prone position at 1- and 4-h intervals. Ventilator settings were unchanged. Thirty-two consecutive patients were studied 1 h before, 1 and 4 h during and 1 h after placing in a prone position with PaO2/F(I)O2 of 103 +/- 28, 158 +/- 62, 159 +/- 59, and 128 +/- 52, respectively (ANOVA, p < 0.001). After 1 h in a prone position, improvement of PaO2/F(I)O2 by 20 mm Hg or more was considered a positive response. Seven patients studied had no response (22%), hereafter referred to as nonresponders, and 25 had a positive response (78%), hereafter referred to as responders. Among the seven nonresponders, two did not tolerate the prone position and were returned supine before the end of the 4-h trial. With the remaining five, PaO2/F(I)O2 evolution was 83 +/- 29, 77 +/- 19, 83 +/- 33, and 81 +/- 47, respectively. For two of the 25 responders, measurements are missing after returning to the supine position. In 10 of the 23 responders (43%) who completed the 4 h prone trial, the PaO2/F(I)O2 returned to its starting value when patients were repositioned supine: 117 +/- 24, 164 +/- 44, 156 +/- 55, and 110 +/- 34, respectively (ANOVA, p < 0.01). In 13 of the 23 (57%) improvement persisted: 105 +/- 27, 187 +/- 58, 189 +/- 49, and 157 +/- 49, respectively (ANOVA, p < 0.001). Repeated improvements after turning to a prone position were frequently observed. Side effects in the 32 patients after a total of 294 periods in a prone position included minor skin injury and edema, two instances of apical atelectasis, one catheter removal, one catheter compression, one extubation, and one transient supraventricular tachycardia.

Hepatic cytolytic and cholestatic changes related to a change of lipid emulsions in four long-term parenteral nutrition patients with short bowel.

Long-term parenteral nutrition hepatic-related impairment is commonly reported and diversely explained. However, with a low cyclic caloric intake (100% to 130% of basal metabolism calculated with the Harris-Benedict formula) consisting of two-thirds glucose, one-third lipid, and 0.20 to 0.25 g of nitrogen per kilogram per day, these complications were infrequent in a clinical practice of home long-term parenteral nutrition. Retrospectively, it was noticed that the switch from Intralipid 20% to Ivelip 20% at the same amount was followed within 2 months by four cases of jaundice in a population of four home long-term parenteral nutrition patients with short bowel disease. Hepatic disturbances were characterized by cytolysis and cholestasis and were reversible after switching from Ivelip 20% back to Intralipid 20%. Neither viral, nor biliary, nor septic etiologies were detected. The exact pathological mechanism remains unknown. The basal composition of both lipid emulsions seems to be identical: soy oil emulsion emulsified by egg phospholipids. However, some differences exist such as the size of particles, the presence of sodium oleate in Ivelip 20%, and the purification process of lecithin. These may explain the difference in hepatic tolerance during long-term parenteral nutrition.

[Massive small bowel resection. Apropos of 27 cases]. / Entérectomies massives. A propos de 27 observations.

27 patients were admitted in the Digestive intensive care unit of Croix-Rousse Hospital after a massive bowel resection (residual bowel 120 cm). The etiology was of vascular origin in 15 cases. The length of intestine was nil in 4 cases, between 20 and 50 cm in 12 cases, and between 50 and 120 cm in 11 cases. A colon resection was performed in 20 cases. For 5 patients, a "double temporary intestinal stoma" for ischemic bowel was made. A "second look laparotomy" was performed in 11 cases. The definitive intestinal continuity restauration was made in 23 cases (7 immediately, 16 later) with 3 duodenocolic anastomoses. 8 patients were able to find back a oral alimentation. 19 patients (with 4 total bowel resections) received a home parenteral nutrition. Actually, 11 are alive.

Severe falciparum malaria (21 cases).

The incidence of severe falciparum malaria is increasing in the developed countries and mortality remains high despite progress in intensive care management and schizonticide treatment. Many authors emphasize the importance of exchange transfusion (EXT) in the most severe cases. We studied 21 cases (34 +/- 12 years, 6 females; SAPS: 8.4 +/- 3.7) of severe malaria (according to WHO criteria) consecutively admitted to ICU between 1985 and 1990: 3 patients underwent EXT. Twenty were febrile above 39 degrees C, 10 had cerebral malaria, 14 hepatic impairment, 8 acute renal failure, 5 pulmonary oedema. Nine patients required mechanical ventilation, 1 haemodialysis, 1 intracranial pressure monitoring. Mean parasitemia was 13%, 16 patients had thrombocytopenia less than 50 x 10(9)/l, 3 anemia less than 7 g/dl and 3 leucopenia less than 2.8 x 10(9)/l. Nineteen received quinine i.v., 1 mefloquine, 1 chloroquine. Sixteen patients received blood products transfusion, 3 were treated by EXT in addition. Twenty were cured and discharged from hospital without sequelae (mean stay: 14 days); 4 had nosocomial infection, 1 a splenic infarction. One patient (17-years-old; SAPS: 17; parasitemia: 7.8%) died 12 h after admission from non-cardiogenic pulmonary oedema with multi-organ failure. The literature and this study lead us to propose EXT in patients with unfavourable evolution after conventional treatment rather than in all the patients with a parasitemia above 10% at admission. A randomized study to compare conventional treatment in ICU with or without EXT is necessary.

[Current modalities of mechanical ventilation for acute respiratory failure in chronic respiratory insufficiency]. / Modalités actuelles de la ventilation mécanique des décompensations aiguës des insuffisants respiratoires chroniques.

Acute respiratory failure in patients with chronic obstructive lung disease is a frequent and serious complication, with a mortality rate of 20 p. 100 and 57 p. 100 of the patients kept under mechanical ventilation for more than two weeks. The main problem with mechanical ventilation is an unavoidable intrinsic positive expiratory pressure and a hyperinflation that can be increased by the different modes of ventilation. All the classical modes of mechanical ventilation may be used, including control-mode ventilation, assist/control-mode ventilation, intermittent mandatory ventilation and ventilation with inspiratory assistance. Another major problem is weaning from mechanical ventilation as it may take a long time or even be impossible, so that the patients stay in intensive care units for ages or require long-term home ventilation. At the moment, there is no way of predicting the outcome of weaning in each individual subjects, and none of the various ventilation procedures has proved superior to the others. Nasal ventilation has recently been introduced in intensive care where it constitutes a major step forward being less invasive; it avoids intubation in 60 p. 100 of the patients but is more exacting for the physicians and nursing staff; finally, it makes it possible to treat acute respiratory failure at an earlier stage than previously.

Nosocomial maxillary sinusitis during mechanical ventilation: a prospective comparison of orotracheal versus the nasotracheal route for intubation.

Nosocomial maxillary sinusitis during mechanical ventilation may cause life-threatening complications in ICU patients. The aim of this prospective study was to compare the incidence of maxillary sinusitis according to the route of intubation. 111 consecutive adult patients (mean age: 53, mean SAPS: 12) were randomly assigned to receive either orotracheal (n = 53) or nasotracheal (n = 58) intubation. All had a nasogastric feeding tube. Patients with head trauma or mechanical ventilation for less than 48 h were excluded. Sinusitis diagnosis was made by radiography (waters' view) at the bedside. The two groups were similar in age, SAPS, duration of ventilation. Maxillary sinusitis occurred in 1/53 (1.8%) of the orotracheal group (on the nasogastric tube side), and in 25/58 (43.1%) of the nasotracheal group (7 on the nasogastric tube side, 11 on the endotracheal tube side, 7 bilateral; p less than 0.001). Nine of the 26 cases of sinusitis were initially treated by sinus drainage because of signs of infection (3 failures) and the 17 others were treated by tube removal. This procedure proved successful in 12 out of 17 cases but secondary drainage was performed in 5 cases (1 failure). Incidents related to the route for long-term intubation were significantly (p less than 0.001) more frequent in the orotracheal group (8/53 vs 2/58), however no patient died because of them. In this study, long-term orotracheal intubation reduced significantly the incidence of maxillary sinusitis in comparison with nasotracheal intubation.

[Fulminant and subfulminant hepatitis treated by orthotopic transplantation of the liver. Apropos of 10 cases]. / Hépatites fulminantes et sub-fulminantes traitées par transplantation orthotopique du foie. A propos de dix cas.

In the period between 15/12/1987 and 15/08/1989, ten patients with either fulminating or subfulminating hepatitis have been treated by orthotopic liver transplantation (O.L.T.). Six patients are doing well in the post-operative period with a mean follow-up of 12 months (7-23 months). No evidence of neurological sequelae has been observed and recurrence of HB virus infection was absent from the three cases who survived hepatitis B transplantation. Four out these ten patients died after initial successful O.L.T... One patient succumbed 7 days after O.L.T. from sepsis or early super-acute rejection, the second 21 days after O.L.T. from neuromeningeal listeria, the third 43 days post O.L.T. from acute rejection, while the fourth developed cytomegalovirus pneumonia and died 61 days after O.L.T. Orthotopic liver transplantation has become the treatment of fulminating hepatitis. It is an emergency which is usually accompanied by successive difficulties in decision making: indication criteria, then acceptance or refusal of ABO incompatible grafts (5/10) and of suboptimal donors. Orthotopic liver transplantation for fulminating hepatitis is technically easy to perform, but usually requires the use of extra-corporal veno-venous circulation. Accompanying intensive medical care is essential and usually includes one or multiple plasmaphereses to correct existing coagulopathy without any fluid or sodium overload to the circulation.