Factors of loss to follow-up during tuberculosis treatment in a low-incidence region.

OBJECTIVE: The proportion of successfully treated tuberculosis (TB) patients remains below the WHO target in France, because of a high proportion of loss to follow-up. We aimed to identify factors associated with loss to follow-up in northern France, a low-incidence area. METHODS: Between 1997 and 2017, all consecutive patients diagnosed with TB at the Tourcoing Hospital, except those infected with multidrug-resistant or extensively drug-resistant strains, were included in a retrospective cohort study. A logistic regression analysis was performed to determine factors associated with loss to follow-up. RESULTS: One hundred and ninety patients were included. Previous TB treatment was reported in 32 patients (17%), extrapulmonary TB in 107 (56%), and HIV infection in 44 (23%). The proportion of loss to follow-up was 15%. In multivariate analysis, the risk of loss to follow-up decreased in case of first TB treatment (OR 0.36; 95% CI: 0.14-0.92, P=0.03) and increased in non-HIV-infected patients (OR 7.67; 95% CI: 1.00-59.0, p=0.05). Support for compliance was more frequent in HIV-infected patients (23% vs. 7%, p=0.005). CONCLUSION: The proportion of loss to follow-up was high. HIV infection was associated with a lower risk of loss to follow-up, likely to be due to more frequent support for compliance.

Med Diet 4.0: the Mediterranean diet with four sustainable benefits.

OBJECTIVE: To characterize the multiple dimensions and benefits of the Mediterranean diet as a sustainable diet, in order to revitalize this intangible food heritage at the country level; and to develop a multidimensional framework - the Med Diet 4.0 - in which four sustainability benefits of the Mediterranean diet are presented in parallel: major health and nutrition benefits, low environmental impacts and richness in biodiversity, high sociocultural food values, and positive local economic returns. DESIGN: A narrative review was applied at the country level to highlight the multiple sustainable benefits of the Mediterranean diet into a single multidimensional framework: the Med Diet 4.0. Setting/subjects We included studies published in English in peer-reviewed journals that contained data on the characterization of sustainable diets and of the Mediterranean diet. The methodological framework approach was finalized through a series of meetings, workshops and conferences where the framework was presented, discussed and ultimately refined. RESULTS: The Med Diet 4.0 provides a conceptual multidimensional framework to characterize the Mediterranean diet as a sustainable diet model, by applying principles of sustainability to the Mediterranean diet. CONCLUSIONS: By providing a broader understanding of the many sustainable benefits of the Mediterranean diet, the Med Diet 4.0 can contribute to the revitalization of the Mediterranean diet by improving its current perception not only as a healthy diet but also a sustainable lifestyle model, with country-specific and culturally appropriate variations. It also takes into account the identity and diversity of food cultures and systems, expressed within the notion of the Mediterranean diet, across the Mediterranean region and in other parts of the world. Further multidisciplinary studies are needed for the assessment of the sustainability of the Mediterranean diet to include these new dimensions.

Complications following intravesical bacillus Calmette-Guerin treatment for bladder cancer: a case series of 22 patients.

BACKGROUND: Intravesical bacillus Calmette-Guerin (BCG) therapy is an effective and widely used treatment for superficial bladder carcinoma. Local complications are frequent whereas systemic complications are rare but can be serious, and their management is not well known. METHODS: We describe retrospectively the records of 22 patients treated in 3 infectious disease departments, for complications related to intravesical BCG therapy as treatment of bladder cancer. RESULTS: All the patients were male, with a median age of 68 years (range 56-88). Complications occurred after a median of 5 instillations (range 1-11) and were observed within 24 h following BCG instillation for 14 patients. Common symptoms were fever (n = 20), impaired general condition (n = 14), and shortness of breath (n = 7). Six patients had a systemic septic reaction leading to transfer into the intensive care unit for five of them. Lung infiltration was the most frequent presentation (n = 11). Mycobacterium bovis was isolated from only two patients, but histology showed the presence of a granuloma in nine patients. Antimycobacterial treatment was initialized in 17 patients; the outcome was favorable in 16 patients, with a median length of symptoms resolution of 22.5 days (range 5-425 days). Eleven patients received corticosteroids in addition to specific treatment and had a more rapid improvement. One patient died with disseminated BCGitis proved by biopsy. CONCLUSIONS: Complications following intravesical BCG therapy are rare but can be severe and fatal. Histology seems to be the method that contributes most in confirmation of the diagnosis. Antimycobacterial therapy is effective, and probably more efficient when combined with corticosteroids, but the regimen and duration of the treatment are not standardized.

Tropical infection after a case of total hip arthroplasty.

In non-endemic areas, malaria is mainly an imported disease. This article reports a case of transfusion-related Plasmodium falciparum malaria in a non-endemic area. Despite initial clinical signs consistent with malaria, the diagnosis was not elicited because of the absence of any identified epidemiological risk factors. The case indicates that transfusion-transmitted malaria still occurs in non-endemic countries. The role of laboratory testing to prevent and diagnose transfusion-transmitted malaria in non-endemic malaria countries is crucial.

Management and control of a carbapenem-resistant Acinetobacter baumannii outbreak in an intensive care unit.

OBJECTIVE: We had for aim to describe the identification and management of a 14-clonal carbapenem-resistant Acinetobacter baumannii (CRAB) outbreak, following admission of a known CRAB-infected patient in an ICU. METHODS: We reviewed the carriers' files and outbreak management procedures. RESULTS: The index patient was admitted with strict isolation precautions. The outbreak started 2 months after his discharge. It persisted despite reinforcement of strict isolation precautions, staff and patient cohorting, and extensive environmental decontamination including 2 rounds of routine terminal cleaning and disinfection or 1 round of cleaning and disinfection followed by hydrogen peroxide treatment. A second epidemic peak, after 4 weeks without any case, led to another wide environmental sampling and decontamination rounds. The source of the CRAB outbreak was suspected to be the blood pressure cuffs Velcro. Switching to cuffs submersible in a disinfectant stopped the outbreak. CONCLUSIONS: CRAB outbreaks are difficult to manage and sources of persistent colonization can be unexpected.

Clostridium difficile colitis acquired in the intensive care unit: outcome and prognostic factors.

PURPOSE: We assessed factors associated with mortality and complicated course in the case of Clostridium difficile infection (CDI) acquired in the intensive care unit (ICU). METHOD: Retrospective cohort study conducted from 1 January 2002 through 1 January 2012. All patients who acquired CDI in our ICU were included. RESULTS: Thirty-one patients were included. Twenty patients (65 %) had mild colitis, 8 (25 %) moderate colitis, and 3 (10 %) severe colitis. Initial antibiotherapy was metronidazole (n = 30, 97 %) and vancomycin (n = 1, 3 %). Seventeen patients (55 %) experienced at least one complication: failure of initial treatment (n = 16, 52 %), shock (n = 11, 34 %), need for surgery (n = 1, 3 %) or renal replacement (n = 4, 13 %), or death (n = 8, 26 %). Risk factors of ICU mortality were history of corticosteroids prescription, prolonged ICU stay, low serum albumin level, and high Sequential Organ Failure Assessment (SOFA) score at the time of CDI diagnosis. Factors associated with a complicated course were high Simplified Acute Physiology Score (SAPS II), high SOFA score, and low serum albumin level at the time of CDI onset. CONCLUSION: Risk factors of poor outcome in patients with CDI acquired in the ICU are different from those in the general population suffering from CDI. The implementation of treatment algorithms taking into account these factors may reduce complication rates in this specific population.

Clinical spectrum and outcome of critically ill patients suffering from prosthetic joint infections.

PURPOSE: To report the clinical characteristics and prognosis of prosthetic joint infections (PJIs) in Intensive care units (ICUs). METHODS: Forty-one patients consecutively admitted to ICUs for PJIs between January 2004 and June 2011 were included in a retrospective case series. RESULTS: A majority of patients (73 %) had severe underlying disease. Acute infection affected 26 patients (63 %). Blood cultures were positive in 16 patients (39 %). Staphylococcus species were the most commonly implicated causative organisms (n = 36, 88 %). The surgical strategy was two-stage replacement in 25 cases (61 %). The surgical procedure leading to ICU admission was mainly prosthesis removal with spacer implantation (n = 13, 32 %). Initial antibiotherapy was a broad-spectrum beta-lactam antibiotic combined with a glycopeptide, linezolid, or daptomycin in 26 cases (63 %). Mortality in the ICU was 20 %. In nonsurvivors, diabetes, acute infection, and American Society of Anesthesiologists (ASA) score >3 were more frequent. The distribution of surgical strategies and procedures was not statistically different in survivors and nonsurvivors. The proportion of patients treated with antibiotherapy adjusted according to previous microbiological findings was higher in nonsurvivors (50 vs. 12 %, p = 0.02). CONCLUSIONS: In our case series of critically ill patients suffering from PJI, factors associated with a poor outcome were diabetes mellitus, ASA score >3, and acute infection. Surgical strategies and surgical procedures had no significant impact on the ICU mortality. Adjustment of initial antibiotherapy according to previous microbiological findings should be made with caution.

Impact of combination therapy with aminoglycosides on the outcome of ICU-acquired bacteraemias.

Pharmacodynamic studies report on the rapid bactericidal activity of aminoglycosides, conferring them as being of theoretical interest for bacteraemia treatment. We assessed this issue in a retrospective study of patients with intensive care unit (ICU)-acquired bacteraemias. To determine the impact of aminoglycosides in antimicrobial combination on the outcome of patients with bacteraemia, we performed a monovariate analysis and a logistic regression analysis comparing patients treated with or without aminoglycosides. Forty-eight bacteraemias in 48 patients were included. Eighteen patients received aminoglycosides. Baseline characteristics as well as adaptation and adequation of antibiotherapy did not differ in patients who did or did not receive aminoglycosides. Patients who received aminoglycosides had longer time alive away from the ICU (11.3 ± 8.9 (10 [0-20]) vs. 3.2 ± 6.6 (0 [0-2] days; p = 0.002) and free from mechanical ventilation (12.5 ± 9.3 (14 [0-21] vs. 5.5 ± 9.2 (0 [0-10] days; p = 0.02) on day 28. The ICU mortality was 16% in the aminoglycoside group versus 46% (p = 0.03). In the multivariate analysis, patients treated with aminoglycosides were 6 times less likely to die than those treated without aminoglycosides (confidence interval [CI] = [1.3-28.9]; p = 0.02). Our study supports the hypothesis that combination short-term antibiotherapy with an aminoglycoside for ICU-acquired bacteraemias could increase survival.

Diagnosis and management of prosthetic vascular graft infections.

Prosthetic vascular graft infection is a rare but very severe complication with a high death rate. Its optimal management requires appropriate surgical procedures combined with adequate antimicrobial treatment in reference center. The authors wanted to focus on the management of prosthetic vascular graft infection and define the clinical, microbiological, biological, and radiological criteria of vascular graft infection. Complementary investigations, although these are small series, include CT scan, the gold standard for the diagnosis of acute infection with a sensitivity and specificity reaching 100%, but decreased to 55% in case of chronic infection. More recently, PET-scanning was studied and yielded good results in chronic infections (sensitivity 98%, specificity 75.6%, positive predictive value 88.5%, and negative predictive value 84.4%). Managing prosthetic vascular graft infection, as with the orthopedic and vascular infections, requires replacing the vascular prosthesis. There is no correlation between the microbiological data and the location or type of vascular infection. Thus, the postoperative intravenous antibiotherapy should be bactericidal with a broad-spectrum. After obtaining intra-operative microbiological results, de-escalation therapy must include at least one anti-adherence agent, such as rifampicin in staphylococcal infections.

[An acute respiratory distress syndrome revealing a chronic eosinophilic pneumonia]. / Un syndrome de détresse respiratoire aiguë inaugural d'une pneumopathie chronique idiopathique à éosinophiles.

Idiopathic chronic eosinophilic pneumonia (ICEP) is one of the idiopathic hypereosinophilic lung diseases. ICEP differs from idiopathic acute eosinophilic pneumonia (IAEP) by its progressive onset, and the absence of severe hypoxemia. We report a case of acute respiratory distress syndrome revealing an ICEP, which needed a 48h of mechanical ventilation. ICEP is an exceptional cause of acute respiratory failure. Symptoms always improve with corticosteroids. But relapses are frequent after stopping corticosteroid treatment, as well as the occurrence of severe asthma. Distinction between ICEP and IAEP is essential because of its impact on treatment duration and on prognosis.

Multidrug-resistant tuberculous meningitis in an HIV-positive patient: a challenging disease.

We report two cases of disseminated multidrug-resistant tuberculosis with meningitis in HIV-positive patients, who were both recent emigrants from sub-Saharan Africa. Our two cases highlight new challenges in the care of HIV and tuberculosis coinfection including early diagnosis and treatment of multidrug-resistant tuberculosis that is spreading.

Induction of the skin endogenous protective mitochondrial MnSOD by Vitreoscilla filiformis extract.

Vitreoscilla filiformis (Vf), a filamentous bacteria living in fresh water is thought to contribute to the observed beneficial effects of Spa water on skin. An active fraction obtained from a Vf biomass was evaluated for its ability to modulate mRNA expression in cultured skin cells. cDNA array analysis was conducted first using a customized membrane including 1176 selected and fully identified genes involved in skin physiology and homeostasis then the newly developed full genome U133 plus 2.0 GeneChip from Affymetrix. The mitochondrial protective manganese superoxide dismutase (MnSOD/SOD-2) was identified as a preferentially induced mRNA target in both normal human dermal fibroblasts and keratinocytes. Induction at the transcriptional level in both cell types was confirmed using quantitative real time/polymerase chain reaction and a kinetic analysis revealed a maximal increase in mRNA expression 20 h after stimulation with Vf extract (Vfe). Using immunofluorescent (fluorescent cell sorter) analysis, an induction of MnSOD protein in both normal human dermal skin fibroblasts (x1.6; P < 0.01) and epidermal keratinocytes (x1.4; P < 0.01) was confirmed. As MnSOD is a major inducible free-radical scavenger in skin, these results suggest that the Vfe could induce skin cells to produce their own endogenous protective defences in vivo against both exogenous environmental stressors such as UV irradiation or microflora as well as to combat endogenous sources of deleterious free radicals involved in skin ageing. Finally, in order to confirm the in vivo potential of this original extract in human, we evaluated its protective activity vs. placebo on the generation of sunburn cells in epidermis under UVB stress. As expected from in vitro profiling, Vfe was indeed found to significantly inhibit the appearance of sunburn cells in UVB-exposed areas, a signature of skin alteration which has been suggested to be linked to a defect in MnSOD protective activity. Altogether, those data suggest that the combination of a suitable protective UV filter together with this bioactive Vfe might improve skin protection through complementary pathways.

[Involvement of the nasal sinuses in sarcoidosis. A prospective study of 63 patients]. / Atteinte nasosinusienne au cours de la sarcoïdose. Etude prospective chez 62 patients atteints de sarcoïdose.

INTRODUCTION: Sarcoidosis is a diffuse granulomatous inflammatory disorder of unknown aetiology. Involvement of the nasal sinuses has been reported only rarely. METHODS: This multicentre prospective study was undertaken on patients suffering from histologically confirmed sarcoidosis between October 2001 and August 2002. It comprised a questionnaire for nasal symptoms, a nasal endoscopy and a CT scan of the nasal sinuses. RESULTS: Among the 62 patients enrolled 38 reported at least one nasal sinus symptom. An abnormality of the CT scan was present in 70% of cases. None were specific for sarcoidosis. Rhinoscopy revealed a mucosal lesion in 11 cases. The presence of mucosal nodules on the turbinates was suggestive of sarcoidosis and was proven histologically in 4 cases (6.5%). In these 4 cases there were symptoms of nasal sinus involvement and extensive CT changes. CONCLUSIONS: Involvement of the nasal sinuses is rare in the course of sarcoidosis. Anterior rhinoscopy allows diagnosis before the development of typical lesions and also the taking of guided biopsies.

[A rare complication of chronic pancreatitis: pancreatico-pleural fistula]. / Une complication rare d'une pancréatite chronique: la fistule pancréatico-pleurale.

Pleural effusion is a rare complication of chronic pancreatitis. We report a case observed in a 39-year-old patient hospitalized for dyspnea and pain in the lower left thorax. Chest x-ray revealed left pleural effusion. The exudative pleural fluid contained a very high amylase level. CT-scan revealed a pseudo-cyst of the tail of the pancreas extending into contact with the diaphragm and the chronic pancreatitis lesions. Medical treatment associating thoracic drainage, somatostatin analog, and antibiotics was unsuccessful. Thoracoscopic pleural decortication was performed. The patient then developed pneumonia involving the left base. A new antibiotic regimen was delivered and the pseudocyst was drained percutaneously under CT guidance. The clinical course was favorable at six months with partial involution of the pseudocyst and regression of the pulmonary images.