RÉSUMÉ
Night work is frequently associated with sleep deprivation and is associated with greater surgical and medical complications. Lung transplantation (LT) is carried out both at night and during the day and involves many medical healthcare workers. The goal of the study was to compare morbidity and mortality between LT recipients according to LT operative time. We performed a retrospective, observational, single-center study. When the procedure started between 6 AM and 6 PM, the patient was allocated to the Daytime group. If the procedure started between 6 PM and 6 AM, the patient was allocated to the Nighttime group. Between January 2015 and December 2020, 253 patients were included. A total of 168 (66%) patients were classified into the Day group, and 85 (34%) patients were classified into the Night group. Lung Donors' general characteristics were similar between the groups. The 90-day and one-year mortality rates were similar between the groups (90-days: n = 13 (15%) vs. n = 26 (15%), p = 0.970; 1 year: n = 18 (21%) vs. n = 42 (25%), p = 0.499). Daytime LT was associated with more one-year airway dehiscence (n = 36 (21%) vs. n = 6 (7.1%), p = 0.004). In conclusion, among patients who underwent LT, there was no significant association between operative time and survival.
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Transplantation pulmonaire , Durée opératoire , Humains , Transplantation pulmonaire/effets indésirables , Transplantation pulmonaire/mortalité , Mâle , Femelle , Études rétrospectives , Adulte d'âge moyen , Adulte , Complications postopératoires/épidémiologie , Complications postopératoires/étiologie , Privation de sommeil/complications , Sujet âgéRÉSUMÉ
Introduction: Although many studies have underscored the importance of T cells, phenotypically and functionally, fewer have studied the functions of myeloid cells in COVID disease. In particular, the potential role of myeloid cells such as monocytes and low-density neutrophils (LDNs) in innate responses and particular in the defense against secondary bacterial infections has been much less documented. Methods: Here, we compared, in a longitudinal study, healthy subjects, idiopathic fibrosis patients, COVID patients who were either hospitalized/moderate (M-) or admitted to ICU (COV-ICU) and patients in ICU hospitalized for other reasons (non-COV-ICU). Results: We show that COVID patients have an increased proportion of low-density neutrophils (LDNs), which produce high levels of proteases (particularly, NE, MMP-8 and MMP-9) (unlike non-COV-ICU patients), which are partly responsible for causing type II alveolar cell damage in co-culture experiments. In addition, we showed that M- and ICU-COVID monocytes had reduced responsiveness towards further live Pseudomonas aeruginosa (PAO1 strain) infection, an important pathogen colonizing COVID patients in ICU, as assessed by an impaired secretion of myeloid cytokines (IL-1, TNF, IL-8, ). By contrast, lymphoid cytokines (in particular type 2/type 3) levels remained high, both basally and post PAO1 infection, as reflected by the unimpaired capacity of T cells to proliferate, when stimulated with anti-CD3/CD28 beads. Discussion: Overall, our results demonstrate that COVID circulatory T cells have a biased type 2/3 phenotype, unconducive to proper anti-viral responses and that myeloid cells have a dual deleterious phenotype, through their LDN-mediated damaging effect on alveolar cells and their impaired responsiveness (monocyte-mediated) towards bacterial pathogens such as P. aeruginosa.
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COVID-19 , Monocytes , Granulocytes neutrophiles , Infections à Pseudomonas , Pseudomonas aeruginosa , SARS-CoV-2 , Humains , COVID-19/immunologie , Pseudomonas aeruginosa/immunologie , Monocytes/immunologie , Mâle , Femelle , Adulte d'âge moyen , SARS-CoV-2/immunologie , SARS-CoV-2/physiologie , Infections à Pseudomonas/immunologie , Granulocytes neutrophiles/immunologie , Sujet âgé , Cytokines/métabolisme , Cytokines/immunologie , Adulte , Études longitudinales , Agranulocytes/immunologie , Poumon/immunologie , Poumon/anatomopathologie , Poumon/microbiologieRÉSUMÉ
In this work, we present a new approach to predict the risk of acute cellular rejection (ACR) after lung transplantation by using machine learning algorithms, such as Multilayer Perceptron (MLP) or Autoencoder (AE), and combining them with topological data analysis (TDA) tools. Our proposed method, named topological autoencoder with best linear combination for optimal reduction of embeddings (Taelcore), effectively reduces the dimensionality of high-dimensional datasets and yields better results compared to other models. We validate the effectiveness of Taelcore in reducing the prediction error rate on four datasets. Furthermore, we demonstrate that Taelcore's topological improvements have a positive effect on the majority of the machine learning algorithms used. By providing a new way to diagnose patients and detect complications early, this work contributes to improved clinical outcomes in lung transplantation.
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Transplantation pulmonaire , , Humains , Algorithmes , Apprentissage machineRÉSUMÉ
PURPOSE: To assess the Consultation And Relational Empathy (CARE) measure as a tool for examiners to assess medical students' empathy during Objective and Structured Clinical Examinations (OSCEs), as the best tool for assessing empathy during OSCEs remains unknown. METHODS: We first assessed the psychometric properties of the CARE measure, completed simultaneously by examiners and standardized patients (SP, either teachers - SPteacher - or civil society members - SPcivil society), for each student, at the end of an OSCE station. We then assessed the qualitative/quantitative agreement between examiners and SP. RESULTS: We included 129 students, distributed in eight groups, four groups for each SP type. The CARE measure showed satisfactory psychometric properties in the context of the study but moderate, and even poor inter-rater reliability for some items. Considering paired observations, examiners scored lower than SPs (p < 0.001) regardless of the SP type. However, the difference in score was greater when the SP was a SPteacher rather than a SPcivil society (p < 0.01). CONCLUSION: Despite acceptable psychometric properties, inter-rater reliability of the CARE measure between examiners and SP was unsatisfactory. The choice of examiner as well as the type of SP seems critical to ensure a fair measure of empathy during OSCEs.
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BACKGROUND: While the role of Extended Focused Assessment with Sonography in Trauma (eFAST) is well defined in the management of severe blunt trauma, its performance in injuries caused by stab wounds has been poorly assessed. METHODS: Prospective single centre study which included all patients with stab wounds to the thorax or abdomen between December 2016 and December 2018. All patients underwent initial investigation with both eFAST and CT scan, except in cases of haemodynamic or respiratory instability, and in cases with a positive diagnosis by eFAST in which case surgery without CT scan was performed. RESULTS: Of the 200 consecutive patients included, 14 unstable patients underwent surgery immediately after eFAST. In these 14 patients, 9 had cardiac tamponade identified by eFAST and all were confirmed by surgery. In the remaining 186 patients, the median time between eFAST and CT scan was 30 min (IQR 20-49 min). Test characteristics (including 95% CI) for eFAST compared with reference standard of CT scan for detecting pneumothorax were as follows: sensitivity 77% (54%-92%), specificity 93% (90%-97%), positive predictive value (PPV) 60% (49%-83%), negative predictive value (NPV) 97% (93%-99%). Test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemothorax were as follows: sensitivity 97% (74%-99%), specificity 96% (92%-98%), PPV 83% (63%-93%) and NPV 99% (96%-100%). Finally, test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemoperitoneum were as follows: sensitivity 75% (35%-97%), specificity 97% (93%-99%), PPV 55% (23%-83%) and NPV 99% (96%-99%). CONCLUSIONS: In patients admitted with stab wounds to the torso, eFAST was not sensitive enough to diagnose pneumothorax and haemoperitoneum, but performed better in the detection of cardiac tamponade and haemothorax than the other injuries. More robust multicentre studies are needed to better define the role of eFAST in this specific population.
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Traumatismes de l'abdomen , Tamponnade cardiaque , Pneumothorax , Blessures du thorax , Plaies non pénétrantes , Plaies par arme blanche , Humains , Pneumothorax/imagerie diagnostique , Pneumothorax/étiologie , Études prospectives , Hémothorax/étiologie , Hémothorax/complications , Tamponnade cardiaque/complications , Hémopéritoine/étiologie , Hémopéritoine/complications , Blessures du thorax/imagerie diagnostique , Blessures du thorax/complications , Sensibilité et spécificité , Échographie , Traumatismes de l'abdomen/imagerie diagnostique , Plaies non pénétrantes/imagerie diagnostique , Plaies non pénétrantes/complications , Plaies par arme blanche/complications , Plaies par arme blanche/imagerie diagnostiqueRÉSUMÉ
BACKGROUND: Early diagnosis of acute mesenteric ischemia (AMI) is essential for a favorable outcome. Selection of patients requiring a dedicated multiphasic computed tomography (CT) scan remains a clinical challenge. METHODS: In this cross-sectional diagnostic study conducted from 2016 to 2018, we compared the presentation of AMI patients admitted to an intestinal stroke center to patients with acute abdominal pain of another origin admitted to the emergency room (controls). RESULTS: We included 137 patients-52 with AMI and 85 controls. Patients with AMI [median age: 65 years (interquartile range 55-74)] had arterial and venous AMI in 65% and 35% of cases, respectively. Relative to controls, AMI patients were significantly older, more likely to have risk factors or a history of cardiovascular disease, and more likely to present with sudden-onset and morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and higher plasma C-reactive protein (CRP) and procalcitonin concentrations. On multivariate analysis, two independent factors were associated with the diagnosis of AMI: the sudden-onset (OR = 20, 95%CI 7-60, p < 0.001) and the morphine-requiring nature of the acute abdominal pain (OR = 6, 95%CI 2-16, p = 0.002). Sudden-onset and/or morphine-requiring abdominal pain was present in 88% of AMI patients versus 28% in controls (p < 0.001). The area under the receiver operating characteristic curve for the diagnosis of AMI was 0.84 (95%CI 0.77-0.91), depending on the number of factors. CONCLUSIONS: Sudden onset and the need for morphine are suggestive of AMI in patients with acute abdominal pain and should prompt multiphasic CT scan including arterial and venous phase images for confirmation.
Sujet(s)
Abdomen aigu , Ischémie mésentérique , Accident vasculaire cérébral , Humains , Sujet âgé , Ischémie mésentérique/diagnostic , Abdomen aigu/diagnostic , Études transversales , Douleur abdominale , Accident vasculaire cérébral/complications , Dérivés de la morphineRÉSUMÉ
OBJECTIVE: Objective structured clinical examinations (OSCE) are one of the main modalities of skills' assessment of medical students. We aimed to evaluate the educational value of the participation of third-year medical students in OSCE as standardized patients. METHODS: We conducted a pilot OSCE session where third-year students participated in sixth-year students' OSCE as standardized patients (cases). Their scores in their own subsequent OSCE exams were compared with third-year students who had not participated (controls). Students' perceptions (stress, preparedness, ease) regarding their OSCE were compared with self-administered questionnaires. RESULTS: A total of 42 students were included (9 cases and 33 controls). Median [IQR] overall score (out of 20 points) obtained by the cases was 17 [16.3-18] versus 14.5 [12.7-16.3] for controls (p < 0.001). Students' perception of their evaluation (difficulty, stress, communication) was not significantly different between cases and controls. Most cases agreed that their participation was beneficial in reducing their stress (67%), increasing their preparedness (78%) and improving their communication skills (100%). All cases agreed that this participation should be offered more widely. CONCLUSION: Students' participation in OSCE as standardized patients led to better performance on their own OSCE and were considered beneficial. This approach could be more broadly generalized to improve student performance.
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Évaluation des acquis scolaires , Étudiant médecine , Humains , Écoles de médecine , Paris , Compétence cliniqueRÉSUMÉ
Pulmonary hypertension (PH) is associated with pulmonary vasoconstriction and endothelial dysfunction leading to impaired nitric oxide (NO) and prostacyclin (PGI2) pathways. Metformin, the first line treatment for type 2 diabetes and AMP-activated protein kinase (AMPK) activator, has been recently highlighted as a potential PH treatment. AMPK activation has been reported to improve endothelial function by enhancing endothelial NO synthase (eNOS) activity and to have relaxant effects in blood vessels. In this study, we examined the effect of metformin treatment on PH as well as on NO and PGI2 pathways in monocrotaline (MCT)-injected rats with established PH. Moreover, we investigated the anti-contractile effects of AMPK activators on endothelium-denuded human pulmonary arteries (HPA) from Non-PH and Group 3 PH patients (due to lung diseases and/or hypoxia). Furthermore, we explored the interaction between treprostinil and the AMPK/eNOS pathway. Our results showed that metformin protected against PH progression in MCT rats where it reduced the mean pulmonary artery pressure, pulmonary vascular remodeling and right ventricular hypertrophy and fibrosis compared to vehicle-treated MCT rats. The protective effects on rat lungs were mediated in part by increasing eNOS activity and protein kinase G-1 expression but not through the PGI2 pathway. In addition, incubation with AMPK activators reduced the phenylephrine-induced contraction of endothelium-denuded HPA from Non-PH and PH patients. Finally, treprostinil also augmented eNOS activity in HPA smooth muscle cells. In conclusion, we found that AMPK activation can enhance the NO pathway, attenuate vasoconstriction by direct effects on smooth muscles, and reverse established MCT-induced PH in rats.
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Diabète de type 2 , Hypertension pulmonaire , Metformine , Rats , Humains , Animaux , Hypertension pulmonaire/induit chimiquement , Hypertension pulmonaire/traitement médicamenteux , Hypertension pulmonaire/prévention et contrôle , Artère pulmonaire , Metformine/effets indésirables , AMP-Activated Protein Kinases/métabolisme , Diabète de type 2/métabolisme , Monocrotaline/effets indésirablesRÉSUMÉ
SARS-CoV-2 infection goes beyond acute pneumonia, as it also impacts lipid metabolism. Decreased HDL-C and LDL-C levels have been reported in patients with COVID-19. The lipid profile is a less robust biochemical marker than apolipoproteins, components of lipoproteins. However, the association of apolipoprotein levels during COVID-19 is not well described and understood. The objective of our study is to measure plasma levels of 14 apolipoproteins in patients with COVID-19 and to evaluate the relationships between apolipoprotein levels, severity factors and patient outcomes. From November to March 2021, 44 patients were recruited on admission to the intensive care unit because of COVID-19. Fourteen apolipoproteins and LCAT were measured by LC-MS/MS in plasma of 44 COVID-19 patients on admission to the ICU and 44 healthy control subjects. Absolute apolipoprotein concentrations were compared between COVID-19 patients and controls. Plasma apolipoproteins (Apo) A (I, II, IV), C(I, II), D, H, J and M and LCAT were lower in COVID-19 patients, whereas Apo E was higher. COVID-19 severity factors such as PaO2/FiO2 ratio, SO-FA score and CRP were correlated with certain apolipoproteins. Lower Apo B100 and LCAT levels were observed in non-survivors of COVID-19 versus survivors. To conclude, in this study, lipid and apolipoprotein profiles are altered in COVID-19 patients. Low Apo B100 and LCAT levels may be predictive of non-survival in COVID-19 patients.
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COVID-19 , Cholestérol , Humains , Études de cohortes , Chromatographie en phase liquide , Cholestérol/métabolisme , SARS-CoV-2/métabolisme , Spectrométrie de masse en tandem , Apolipoprotéines , Apolipoprotéines A , Apolipoprotéine B-100 , Unités de soins intensifs , Apolipoprotéine A-I , Apolipoprotéines B , Apolipoprotéine A-IIRÉSUMÉ
Corynebacterium spp. are associated with respiratory infections in immunocompromised hosts. A link with bronchial complications after lung transplantation (LTx) has been suggested. We aimed to assess the link between respiratory sampling of Corynebacterium spp. and significant bronchial complication (SBC) after LTx. We performed a single center retrospective study. Inclusion of LTx recipients with at least one respiratory Corynebacterium spp. sample (July 2014 to December 2018). Subjects were matched to unexposed LTx recipients. Primary outcome was SBC occurrence after Corynebacterium spp. isolation. Secondary outcomes were Corynebacterium spp. persistent sampling, chronic lung allograft dysfunction (CLAD) onset and all-cause mortality. Fifty-nine patients with Corynebacterium spp. sampling with 59 without isolation were included. Corynebacterium spp. identification was not associated with SBC occurrence (32.4% vs. 21.6%, p = 0.342). Previous SBC was associated with further isolation of Corynebacterium spp. (OR 3.94, 95% CI [1.72-9.05]). Previous SBC and corticosteroids pulses in the last 3 months were the only factors associated with increased risk of Corynebacterium spp. isolation in multivariate analysis. Corynebacterium spp. sampling was significantly associated with CLAD onset (27.1% vs. 6.9%, p = 0.021). Corynebacterium spp. isolation was not associated with SBC but with higher risk of CLAD. Whether CLAD evolution is affected by Corynebacterium spp. eradication remains to be investigated.
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Transplantation pulmonaire , Infections de l'appareil respiratoire , Humains , Études rétrospectives , Transplantation pulmonaire/effets indésirables , Poumon , Infections de l'appareil respiratoire/complications , CorynebacteriumRÉSUMÉ
High-density lipoproteins (HDLs), whose main role is the reverse transport of cholesterol, also have pleiotropic anti-inflammatory, antioxidant, anti-apoptotic and anti-infectious properties. During sepsis, HDL cholesterol (HDL-C) concentration is low, HDL particle functionality is altered, and these modifications are correlated with poor outcomes. Based on the protective effects of HDL, we hypothesized that HDL-C levels could be associated with lung transplantation (LT) outcome. We thus looked for an association between basal HDL-C concentration and one-year mortality after LT. In this single-center prospective study including consecutive LTs from 2015 to 2020, 215 patients were included, essentially pulmonary fibrosis (47%) and chronic obstructive pulmonary disease (COPD) (38%) patients. Mortality rate at one-year was 23%. Basal HDL-C concentration stratified nonsurvivors to survivors at one-year (HDL-C = 1.26 [1.12-1.62] mmol/L vs. HDL-C = 1.55 [1.22-1.97] mmol/L, p = 0.006). Multivariate analysis confirmed that HDL-C concentration during the pretransplant assessment period was the only variable inversely associated with mortality. Moreover, mortality at one-year in patients with HDL-C concentrations ≤1.45 mmol/L was significantly higher (log-rank test, p = 0.00085). In conclusion, low basal HDL-C concentrations in candidates for LT are strongly associated with mortality after LT. To better understand this association, further studies in this field are essential and, in particular, a better characterization of HDL particles seems necessary.
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Cholestérol , Transplantation pulmonaire , Humains , Études prospectives , Cholestérol HDL , Analyse multifactorielleRÉSUMÉ
BACKGROUND: The outcomes of lung transplantation (LT) recipients who received a graft from a brain-dead donor after successful resuscitation from cardiac arrest (CA donors) have been poorly described. This study compared the one-year survival of LT recipients depending on the CA status of the donor. METHODS: This prospective observational single-centre study analysed all consecutive patients who underwent LT at Bichat Claude Bernard Hospital, Paris, between January 2016 and December 2020. All donors who experienced CA prior to organ donation, regardless of rhythm or duration, were considered CA donors. The postoperative complications and outcomes of LT recipients were analysed. The one-year survival was compared using Kaplan-Meier curves and log-rank tests. Independent risk factors for one-year mortality were assessed using multivariate analysis (p < 0.05 was considered significant). The Paris North Hospitals Institutional Review Board approved the study. RESULTS: A total of 236 LT recipients were analysed and 66 (28%) received a graft from a CA donor. The median durations of no/low flow were 4 [0-10]/20 [15-30] minutes, respectively. Shockable and non-shockable rhythms were observed in 11 (17%) and 47 (72%) of the CA donors, respectively. The characteristics of the grafts and early postoperative complications were not different in the CA and non-CA groups. Receiving a graft from a CA donor was not an independent risk factor for recipient one-year mortality. CONCLUSION: Receiving a graft from a CA donor did not worsen the outcome of LT recipients. Acceptation of these grafts must be systematically considered to increase the pool of available grafts.
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Arrêt cardiaque , Transplantation hépatique , Humains , Transplantation hépatique/effets indésirables , Donneurs de tissus , Arrêt cardiaque/complications , Mort cérébrale , Complications postopératoires/épidémiologie , Complications postopératoires/étiologie , Poumon , Encéphale , Survie du greffon , Études rétrospectives , Résultat thérapeutiqueRÉSUMÉ
The prevalence, risk factors and outcomes associated with culture-positive preservation fluid (PF) after lung transplantation (LT) are unknown. From January 2015 to December 2020, the microbiologic analyses of PF used to store the cold ischaemia-placed lung graft(s) of 271 lung transplant patients were retrospectively studied. Culture-positive PF was defined as the growth of any microorganism. Eighty-three (30.6%) patients were transplanted with lung grafts stored in a culture-positive PF. One-third of culture-positive PF were polymicrobial. Staphylococcus aureus and Escherichia coli were the most frequently isolated microorganisms. No risk factors for culture-positive PF based on donor characteristics were identified. Forty (40/83; 48.2%) patients had postoperative pneumonia on Day 0 and 2 (2/83; 2.4%) patients had pleural empyema with at least one identical bacteria isolated in culture-positive PF. The 30-day survival rate was lower for patients with culture-positive PF compared with patients with culture-negative PF (85.5% vs. 94.7%, p = 0.01). Culture-positive PF has a high prevalence and may decrease lung transplant recipient survival. Further studies are required to confirm these results and improve understanding of the pathogenesis of culture-positive PF and their management.
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Transplantation pulmonaire , Humains , Études rétrospectives , Transplantation pulmonaire/effets indésirables , Morbidité , Facteurs de risqueRÉSUMÉ
Efforts to understand the molecular mechanisms of COVID-19 have led to the identification of ACE2 as the main receptor for the SARS-CoV-2 spike protein on cell surfaces. However, there are still important questions about the role of other proteins in disease progression. To address these questions, we modelled the plasma proteome of 384 COVID-19 patients using protein level measurements taken at three different times and incorporating comprehensive clinical evaluation data collected 28 d after hospitalisation. Our analysis can accurately assess the severity of the illness using a metric based on WHO scores. By using topological vectorisation, we identified proteins that vary most in expression based on disease severity, and then utilised these findings to construct a graph convolutional network. This dynamic model allows us to learn the molecular interactions between these proteins, providing a tool to determine the severity of a COVID-19 infection at an early stage and identify potential pharmacological treatments by studying the dynamic interactions between the most relevant proteins.
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COVID-19 , Protéome , Humains , SARS-CoV-2 , Glycoprotéine de spicule des coronavirusRÉSUMÉ
BACKGROUND: Airway complications are frequent after lung transplantation (LT), as they affect up to 23% of recipients. The implication of perioperative extracorporeal membrane oxygenation (ECMO) support and haemodynamic instability has never been specifically assessed. The first aim of this study was to explore the impact of perioperative ECMO support on bronchial anastomotic dehiscence (BAD) at Day 90 after LT. METHODS: This prospective observational monocentric study analysed BAD in all consecutive patients who underwent LT in the Bichat Claude Bernard Hospital, Paris, France, between January 2016 and May 2019. BAD visible on bronchial endoscopy and/or tomodensitometry was recorded. A univariate analysis was performed (Fisher's exacts and Mann-Whitney tests), followed by a multivariate analysis to assess independent risk factors for BAD during the first 90 days after LT (p < 0.05 as significant). The Paris North Hospitals Institutional Review Board approved the study. RESULTS: A total of 156 patients were analysed. BAD was observed in the first 90 days in 42 (27%) patients and was the main cause of death in 22 (14%) patients. BAD occurred during the first month after surgery in 34/42 (81%) patients. ECMO support was used as a bridge to LT, during and after surgery in 9 (6%), 117 (75%) and 40 (27%) patients, respectively. On multivariate analysis, ECMO as a bridge to LT (p = 0.04) and septic shock (p = 0.01) were independent risk factors for BAD. CONCLUSION: ECMO as a bridge to LT is an independent risk factor for BAD during the first 90 days after surgery. Close monitoring of bronchial conditions must be performed in these high-risk recipients.
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Oxygénation extracorporelle sur oxygénateur à membrane , Transplantation pulmonaire , Humains , Oxygénation extracorporelle sur oxygénateur à membrane/effets indésirables , Résultat thérapeutique , Études rétrospectives , Transplantation pulmonaire/effets indésirables , Facteurs de risqueRÉSUMÉ
We aimed to describe the prevalence, risk factors, morbidity and mortality associated with the occurrence of bacteraemia during the postoperative ICU stay after lung transplantation (LT). We conducted a retrospective single-centre study that included all consecutive patients who underwent LT between January 2015 and October 2021. We analysed all the blood cultures drawn during the postoperative ICU stay, as well as samples from suspected infectious sources in case of bacteraemia. Forty-six bacteria were isolated from 45 bacteraemic patients in 33/303 (10.9%) patients during the postoperative ICU stay. Staphylococcus aureus (17.8%) was the most frequent bacteria, followed by Pseudomonas aeruginosa (15.6%) and Enterococcus faecium (15.6%). Multidrug-resistant bacteria accounted for 8/46 (17.8%) of the isolates. The most common source of bacteraemia was pneumonia (38.3%). No pre- or intraoperative risk factor for bacteraemia was identified. Recipients who experienced bacteraemia required more renal replacement therapy, invasive mechanical ventilation, norepinephrine support, tracheotomy and more days of hospitalization during the ICU stay. After adjustment for age, sex, type of LT procedure and the need for intraoperative ECMO, the occurrence of bacteraemia was associated with a higher mortality rate in the ICU (aOR = 3.55, 95% CI [1.56-8.08], p = 0.003). Bacteraemia is a major source of concern for lung transplant recipients.
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We evaluated the contribution of artificial intelligence in predicting the risk of acute cellular rejection (ACR) using early plasma levels of soluble CD31 (sCD31) in combination with recipient haematosis, which was measured by the ratio of arterial oxygen partial pressure to fractional oxygen inspired (PaO2/FiO2) and respiratory SOFA (Sequential Organ Failure Assessment) within 3 days of lung transplantation (LTx). CD31 is expressed on endothelial cells, leukocytes and platelets and acts as a "peace-maker" at the blood/vessel interface. Upon nonspecific activation, CD31 can be cleaved, released, and detected in the plasma (sCD31). The study included 40 lung transplant recipients, seven (17.5%) of whom experienced ACR. We modelled the plasma levels of sCD31 as a nonlinear dependent variable of the PaO2/FiO2 and respiratory SOFA over time using multivariate and multimodal models. A deep convolutional network classified the time series models of each individual associated with the risk of ACR to each individual in the cohort.
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Cellules endothéliales , Transplantation pulmonaire , Humains , Intelligence artificielle , Gazométrie sanguine , OxygèneRÉSUMÉ
BACKGROUND: During the COVID-19 first wave in France, the capacity of intensive care unit (ICU) beds almost doubled, mainly because of the opening of temporary ICUs with staff and equipment from anaesthesia. OBJECTIVES: We aim to investigate if the initial management in temporary ICU is associated with a change in ICU mortality and short-term prognosis. DESIGN: Retrospective single-centre cohort study. SETTING: Surgical ICU of the Bichat Claude Bernard University Hospital during the COVID-19 "first wave" (from 18 March to 10 April 2020). PATIENTS: All consecutive patients older than 18 years of age with laboratory-confirmed SARS-CoV-2 infection and/or typical radiological patterns were included during their first stay in the ICU for COVID-19. INTERVENTION: Patients were admitted to a temporary ICU if no room was available in the classical ICU and if they needed invasive mechanical ventilation but no renal replacement therapy or Extracorporeal Membrane Oxygenation (ECMO) in the short term. The temporary ICUs were managed by mixed teams (from the ICU and anaesthesiology departments) following a common protocol and staff meetings. MAIN OUTCOME MEASURE: ICU mortality RESULTS: Among the 59 patients admitted, 37 (62.7%) patients had initial management in the temporary ICU. They had the same characteristics on admission and the same medical management as patients admitted to the classical ICU. ICU mortality was similar in the 2 groups (32.4% in temporary ICUs versus 40.9% in classical ICUs; p=0.58). SAPS-II and ECMO use were associated with mortality in multivariate analysis but not admission to the temporary ICU. CONCLUSION: In an overload context of the ICU of a geographical area, our temporary ICU model allowed access to intensive care for all patients requiring it without endangering them.
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COVID-19 , Études de cohortes , Humains , Unités de soins intensifs , Pandémies , Études rétrospectives , SARS-CoV-2RÉSUMÉ
The generation of antibodies against donor-specific major histocompatibility complex (MHC) antigens, a type of donor-specific antibodies (DSAs), after transplantation requires that recipient's allospecific B cells receive help from T cells. The current dogma holds that this help is exclusively provided by the recipient's CD4+ T cells that recognize complexes of recipient's MHC II molecules and peptides derived from donor-specific MHC alloantigens, a process called indirect allorecognition. Here, we demonstrated that, after allogeneic heart transplantation, CD3ε knockout recipient mice lacking T cells generate a rapid, transient wave of switched alloantibodies, predominantly directed against MHC I molecules. This is due to the presence of donor CD4+ T cells within the graft that recognize intact recipient's MHC II molecules expressed by B cell receptor-activated allospecific B cells. Indirect evidence suggests that this inverted direct pathway is also operant in patients after transplantation. Resident memory donor CD4+ T cells were observed in perfusion liquids of human renal and lung grafts and acquired B cell helper functions upon in vitro stimulation. Furthermore, T follicular helper cells, specialized in helping B cells, were abundant in mucosa-associated lymphoid tissue of lung and intestinal grafts. In the latter, more graft-derived passenger T cells correlated with the detection of donor T cells in recipient's circulation; this, in turn, was associated with an early transient anti-MHC I DSA response and worse transplantation outcomes. We conclude that this inverted direct allorecognition is a possible explanation for the early transient anti-MHC DSA responses frequently observed after lung or intestinal transplantations.
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Production d'anticorps , Alloanticorps , Animaux , Rejet du greffon , Antigènes d'histocompatibilité de classe I , Antigènes d'histocompatibilité de classe II , Humains , Isoantigènes , Souris , Souris de lignée BALB C , Peptides , Récepteurs pour l'antigène des lymphocytes BRÉSUMÉ
INTRODUCTION: The maximum gain in quality of life after lung transplantation (LT) is expected between six months and one year after LT, as the occurrence of chronic lung allograft dysfunction may mask the beneficial effects beyond one year. Thus, the postoperative period could be the cornerstone of graft success. We sought to describe the factors present before postoperative admission to the ICU and associated with favorable, arduous or fatal pathway within 90 days of LT. MATERIALS AND METHODS: We conducted a retrospective single-center study between January 2015 and December 2020. Using multinomial regression, we assessed the demographic, preoperative and intraoperative characteristics of patients associated with favorable (duration of postoperative mechanical ventilation < 3 days and alive at Day 90), arduous (duration of postoperative mechanical ventilation ≥ 3 days and alive at Day 90) or fatal (dead at Day 90) pathway within 90 days of LT. RESULTS: A total of 269 lung transplant patients were analyzed. Maximum graft cold ischemic time ≥ 6 h and intraoperative blood transfusion ≥ 3 packed red blood cells were associated with arduous and fatal pathway at Day 90, whereas intraoperative ECMO was strongly associated with fatal pathway. CONCLUSION: No patient demographics influenced the postoperative pathway at Day 90. Only extrinsic factors involving graft ischemia time, intraoperative transfusion, and intraoperative ECMO determined early postoperative pathway.