Predicting factors for the need of extracorporeal membrane oxygenation for suicide attempts by cardiac medication: a single-center cohort study.

BACKGROUND: Severe poisoning due to the overdosing of cardiac drugs can lead to cardiovascular failure. In order to decrease the mortality rate, the most severe patients should be transferred as quickly as possible to an extracorporeal membrane oxygenation (ECMO) center. However, the predictive factors showing the need for venous-arterial ECMO (VA-ECMO) had never been evaluated. METHODS: A retrospective, descriptive, and single-center cohort study. All consecutive patients admitted in the largest ICU of Reunion Island (Indian Ocean) between January 2013 and September 2018 for beta-blockers (BB), calcium channel blockers (CCB), renin-angiotensin-aldosterone system blockers, digoxin or anti-arrythmic intentional poisonings were included. ECMO implementation was the primary outcome. RESULTS: A total of 49 consecutive admissions were included. Ten patients had ECMO, 39 patients did not have ECMO. Three patients in ECMO group died, while no patients in the conventional group died. The most relevant ECMO-associated factors were pulse pressure and heart rate at first medical contact and pulse pressure, heart rate, arterial lactate concentration, liver enzymes and left ventricular ejection fraction (LVEF) at ICU-admission. Only pulse pressure at first medical contact and LVEF were significant after logistic regression. CONCLUSION: A transfer to an ECMO center should be considered for a pulse pressure < 35 mmHg at first medical contact or LVEF < 20% on admission to ICU.

Necrotizing Skin and Soft Tissue Infections Admitted to Intensive Care Unit in Reunion Island: A Retrospective Cohort Study.

This retrospective and single-center study in Reunion Island (Indian Ocean) assessed frequency, mortality, causative pathogens of severe necrotizing skin, and necrotizing skin and soft tissue infections (NSSTIs) admitted in intensive care unit (ICU). Sixty-seven consecutive patients were included from January 2012 to December 2018. Necrotizing skin and soft tissue infection represented 1.06% of total ICU admissions. We estimate the incidence of NSSTI requiring ICU at 1.21/100,000 person/years in Reunion Island. Twenty (30%) patients were receiving nonsteroidal anti-inflammatory drugs (NSAIDs) prior to admission in ICU and 40 (60%) were diagnosed patients with diabetes. Sites of infection were the lower limb in 52 (78%) patients, upper limb in 4 (6%), and perineum in 10 (15%). The surgical treatment was debridement for 40 patients, whereas 11 patients required an amputation. The most commonly isolated microorganisms were Streptococci (42%) and Gram-negative bacteria (22%).The mortality rate was 25.4%. NSAIDs did not influence mortality when interrupted upon admission to ICU.

[Why does the Ebola virus epidemic continue to plague the Democratic Republic of the Congo?] / Pourquoi l'épidémie à virus Ebola continue-t-elle à sévir en République démocratique du Congo ?

Why does the ebola virus epidemic continue to plague the democratic republic Of the congo?Ebola virus disease outbreak continues in North Kivu and Ituri provinces in the Democratic Republic of the Congo, despite a marked improvement in management of medical care and prevention of the disease. Since August 2018, the disease has been evolving in a complex epidemic field, forgotten by the international press. In the sensitive geopolitic context with this area of armed conflicts more than 20 years, we describe the socio-cultural and geopolitic parameters that have an impact on the evolution of disease in the eastern of Democratic Republic of the Congo.

Pourquoi l'épidémie à virus ebola continue-t-elle à sévir en république démocratique du congo ?Malgré une avancée certaine dans la prise en charge médicale et préventive de la maladie depuis le second semestre 2019, l'épidémie de la maladie à virus Ebola continue de sévir dans les provinces du Nord-Kivu et de l'Ituri en République démocratique du Congo. Débutée en août 2018, cette maladie évolue sur un terrain épidémique complexe et oublié des médias internationaux. Nous décrivons les paramètres socioculturels et géopolitiques qui impactent l'évolution de l'épidémie de la maladie à virus Ebola dans cette région orientale de la République démocratique du Congo en proie à des menaces armées et à une instabilité politique depuis plus de deux décennies.

Postpandemic Influenza Mortality of Venovenous Extracorporeal Membrane Oxygenation-Treated Patients in Reunion Island: A Retrospective Single Center Study.

OBJECTIVES: The aim of the present study was to assess the post-pandemic mortality of influenza in patients receiving venovenous extracorporeal membrane oxygenation (VV-ECMO) in Reunion Island, France, by comparing the incidence with other patients undergoing VV-ECMO. DESIGN: Retrospective, descriptive, and single-center cohort study. The primary outcome was the standardized mortality ratio for influenza based on the quartiles of the Respiratory Extracorporeal Membrane Oxygenation Survival Prediction score (RESP Score) in the reference population of patients undergoing VV-ECMO. SETTING: Intensive care unit (ICU), Felix Guyon Hospital, University Teaching Hospital of La Réunion, La Réunion, France. PARTICIPANTS: Consecutive patients on ECMO with positive polymerase chain reaction for influenza. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred twenty-seven consecutive patients were hospitalized in the ICU with a positive influenza polymerase chain reaction from January 2013 to December 2017. Twenty-four influenza patients underwent ECMO including 18 patients with VV-ECMO. During this period, 72 patients requiring VV-ECMO were hospitalized in the ICU. The overall mortality rate of influenza patients on VV-ECMO was 61% versus 46% for non-influenza patients. The standardized mortality ratio per quartile of RESP Score was 1.28 (95% confidence interval 0.61-2.35). CONCLUSIONS: In Reunion, the mortality of patients undergoing VV-ECMO for severe influenza is not lower than the expected mortality of all patients undergoing VV-ECMO.

Thrombotic thrombocytopenic purpura presenting as a severe peripartum cardiogenic shock: Role of myocardial biopsy and assist device for diagnosis and resuscitation.

We describe the case of a peripartum thrombotic thrombocytopenic purpura with fulminant cardiogenic shock treated with extracorporeal life support. Thrombotic thrombocytopenic purpura should be considered in the case of thrombotic microangiopathy with several or severe organ involvement and needs emergent treatment with plasmapheresis (with or without rituximab). In the case of cardiac involvement, aggressive treatment should be considered given the high mortality and the potential complete recovery.

[Epidemic and emerging prone-infectious diseases: Lessons learned and ways forward]. / Qu'apprend-t-on de nouveau des épidémies émergentes ?

Africa along side with south-east Asia are the epicentres of emerging and epidemic prone-infectious diseases and megacity biosecurity threat scenarios. Massive mobility and reluctance in the populations exposed to epidemic and emerging prone-infectious diseases coupled by a weak health system made disease alert and control measures difficult to implement. The investigation of virus detection and persistence in semen across a range of emerging viruses is useful for clinical and public health reasons, in particular for viruses that lead to high mortality or morbidity rates or to epidemics. Innovating built facility to safely treat patients with highly pathogenic infectious diseases is urgently need, not only to prevent the spread of infection from patients to healthcare workers but also to offer provision of relatively invasive organ support, whenever considered appropriate, without posing additional risk to staff. Despite multiple challenges, the need to conduct research during epidemics is inevitable, and candidate products must continue undergoing rigorous trials. Preparedness including management of complex humanitarian crises with community distrust is a cornerstone in response to high consequence emerging infectious disease outbreaks and imposes strengthening of the public health response infrastructure and emergency outbreak systems in high-risk regions.

Mortality of critically ill patients with severe influenza starting four years after the 2009 pandemic.

Background: In Reunion Island, influenza is not considered a serious illness despite significant mortality in intensive care unit (ICU). We assess the post-pandemic mortality of influenza by comparing it to other community-acquired pneumonia in our ICU. Methods: Retrospective, descriptive, and single-centre cohort study. The main aim was to determine the standardized mortality ratio (SMR) for influenza based on the quartiles of the SAPSII score in the reference population of 954 patients hospitalized for community-acquired pneumonia. Another aim was to analyze the risk factors for mortality in influenza patients. Results: 127 consecutive patients were hospitalized in our ICU with a positive influenza PCR, from January 2013 to December 2017. The mortality rate of these patients was 31% (CI 95%: 23-39%). In patients hospitalized for community-acquired pneumonia, the SMR of patients with influenza was 1.24 (CI 95%: 0.89-1.70). At admission, thirty-nine patients (31%) had superinfections, in 17 caused by methicillin-susceptible Staphylococcus aureus. Need for renal replacement therapy (RR 2.53 [1.29-4.93]) or ECMO (RR 2.35 [1.16-4.74]) were associated with mortality. Twenty-four patients underwent ECMO, 17 with VV-ECMO. Conclusions: Mortality in patients with influenza pneumonia was higher than the expected mortality in community-acquired pneumonia. Although generally considered benign, influenza is a deadly infection in ICU patients in Reunion Island.

Acute respiratory distress syndrome in leptospirosis.

PURPOSE: Acute Respiratory Distress Syndrome is a major complication of leptospirosis, leading to the majority of fatalities. METHODS: Retrospective, descriptive and single-center cohort study. The primary outcome was the Standardized Mortality Ratio (SMR) for ARDS in leptospirosis based on the quartiles of the SAPS2 score in the reference population of 1683 patients hospitalized for ARDS. The second outcomes were to determine the risk factors of mortality of ARDS in leptospirosis and to describe the cases requiring Extracorporeal Membrane Oxygenation (ECMO). RESULTS: Of 172 leptospirosis patients from January 2004 to October 2017, 39 (23%) presented a moderate or severe ARDS with a mortality rate of 23% (9 cases). Among patients with ARDS, the SMR with regards to Simplified Acute Physiology Score II was 0.49 (CI95%: 0.21; 0.96). Risk factors associated with mortality found by bivariate analysis were Severity Acute Physiology Score II (p = 0.01), Sequential Organ Failure Assessment (p = 0.01), base excess (p = 0.002), kaliemia (p = 0.004), bilirubinemia (p = 0.01) and level of aspartate aminotransferase (p = 0.01). Eight patients underwent ECMO for refractory ARDS and six survived. CONCLUSIONS: Leptospirosis can induce serious but transient ARDS with a better prognosis than that of other causes of ARDS. Several patients have been successfully treated with ECMO.

Leptospirosis in ICU: A Retrospective Study of 134 Consecutive Admissions.

OBJECTIVES: Leptospirosis causes reversible multiple organ failure, and its mortality remains high. The aim of this study was to determine the mortality rate of leptospirosis in an ICU offering all types of organ support available nowadays and to compare it with mortality in bacterial sepsis. DESIGN: Retrospective, descriptive, and single-center cohort study. SETTINGS: The largest ICU of Reunion Island (Indian Ocean) in a teaching hospital. PATIENTS: Consecutive patients hospitalized in ICU for leptospirosis from January 2004 to January 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We report 134 cases of patients with leptospirosis hospitalized in ICU. The median age was 40 years (interquartile range, 30-52 yr), with a Simplified Acute Physiology Score II of 38 (27-50) and a Sequential Organ Failure Assessment score of 10 (8-12). Forty-one patients (31%) required mechanical ventilation and 76 (56%) required renal replacement therapy. The door-to-renal replacement therapy time was 0 (0-1) day after admission with a median urea of 25 mmol/L (17-32 mmol/L). Five patients required extracorporeal membrane oxygenation. The mortality rate was 6.0% (95% CI, 2.6-11.4). Among patients hospitalized for sepsis, the standardized mortality ratio of patients with leptospirosis with regards to Simplified Acute Physiology Score II was dramatically low: 0.40 (95% CI, 0.17 - 0.79). CONCLUSIONS: The mortality of severe leptospirosis is lower than for other bacterial infection, provided modern resuscitation techniques are available. Prompt organ support ensures very low mortality rates despite high severity scores.

Right over left ventricular end-diastolic area relevance to predict hemodynamic intolerance of high-frequency oscillatory ventilation in patients with severe ARDS.

BACKGROUND: High-frequency oscillatory ventilation (HFOV) does not improve the prognosis of ARDS patients despite an improvement in oxygenation. This paradox may partly be explained by HFOV hemodynamic side-effects on right ventricular function. Our goal was to study the link between HFOV and hemodynamic effects and to test if the pre-HFOV right over left ventricular end-diastolic area (RVEDA/LVEDA) ratio, as a simple parameter of afterload-related RV dysfunction, could be used to predict HFOV hemodynamic intolerance in patients with severe ARDS. METHODS: Twenty-four patients were studied just before and within 3 h of HFOV using transthoracic echocardiography and transpulmonary thermodilution. RESULTS: Before HFOV, the mean PaO2/FiO2 ratio was 89 ± 23. The number of patients with a RVEDA/LVEDA ratio >0.6 significantly increased after HFOV [11 (46 %) vs. 17 (71 %)]. Although HFOV did not significantly decrease the arterial pressure (systolic, diastolic, mean and pulse pressure), it significantly decreased the cardiac index (CI) by 13 ± 18 % and significantly increased the RVEDA/LVEDA ratio by 14 ± 11 %. A significant correlation was observed between pre-HFOV RVEDA/LVEDA ratio and CI diminution after HFOV (r = 0.78; p < 0.0001). A RVEDA/LVEDA ratio superior to 0.6 resulted in a CI decrease >15 % during HFOV with a sensitivity of 80 % (95 % confidence interval 44-98 %) and a specificity of 79 % (confidence interval 49-95 %). CONCLUSION: The RVEDA/LVEDA ratio measured just before HFOV predicts the hemodynamic intolerance of this technique in patients with severe ARDS. A high ratio under CMV raises questions about the use of HFOV in such patients. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01167621.

Specific management of post-chikungunya rheumatic disorders: a retrospective study of 159 cases in Reunion Island from 2006-2012.

BACKGROUND: Since 2003, the tropical arthritogenic chikungunya (CHIK) virus has become an increasingly medical and economic burden in affected areas as it can often result in long-term disabilities. The clinical spectrum of post-CHIK (pCHIK) rheumatic disorders is wide. Evidence-based recommendations are needed to help physicians manage the treatment of afflicted patients. PATIENTS AND METHODS: We conducted a 6-year case series retrospective study in Reunion Island of patients referred to a rheumatologist due to continuous rheumatic or musculoskeletal pains that persisted following CHIK infection. These various disorders were documented in terms of their clinical and therapeutic courses. Post-CHIK de novo chronic inflammatory rheumatisms (CIRs) were identified according to validated criteria. RESULTS: We reviewed 159 patient medical files. Ninety-four patients (59%) who were free of any articular disorder prior to CHIK met the CIR criteria: rheumatoid arthritis (n=40), spondyloarthritis (n=33), undifferentiated polyarthritis (n=21). Bone lesions detectable by radiography occurred in half of the patients (median time: 3.5 years pCHIK). A positive therapeutic response was achieved in 54 out of the 72 patients (75%) who were treated with methotrexate (MTX). Twelve out of the 92 patients (13%) received immunomodulatory biologic agents due to failure of contra-indication of MTX treatment. Other patients mainly presented with mechanical shoulder or knee disorders, bilateral distal polyarthralgia that was frequently associated with oedema at the extremities and tunnel syndromes. These pCHIK musculoskeletal disorders (MSDs) were managed with pain-killers, local and/or general anti-inflammatory drugs, and physiotherapy. CONCLUSION: Rheumatologists in Reunion Island managed CHIK rheumatic disorders in a pragmatic manner following the outbreak in 2006. This retrospective study describes the common mechanical and inflammatory pCHIK disorders. We provide a diagnostic and therapeutic algorithm to help physicians deal with chronic patients, and to limit both functional and economic impacts. The therapeutic indication of MTX in pCHIK CIR could be approved in future efficacy trials.

CHADS2 and CHA2DS2-VASc scores can predict thromboembolic events after supraventricular arrhythmia in the critically ill patients.

PURPOSE: Prediction of arterial thromboembolic events (ATEs) in relation to supraventricular arrhythmia (SVA) has been poorly investigated in the intensive care unit (ICU). We aimed at evaluating CHADS2 and CHA2DS2-VASc scores to predict SVA-related ATE in the ICU. METHODS: We conducted a prospective observational study including all the patients except those in the postoperative course of cardiac surgery who presented SVA lasting 30 seconds or longer during their ICU stay. We looked for ATE during ICU stay, at the first and sixth month of follow-up after ICU discharge. RESULTS: During the 15-month study period, 108 (12.8%) of 846 ICU patients experienced SVA with 12 SVA-related ATE occurring 6 days (3; 13) (median, 10%-90% percentiles) after SVA onset. In our SVA patients, CHADS2 score was 2 (0; 5), and CHA2DS2-VASc score 3 (0; 7). Both CHADS2 (odds ratio (OR), 1.6 [1.1; 2.4]; P = .01) and CHA2DS2-VASc scores (OR, 1.4 [1.04; 1.8]; P = .03) were significantly associated with ATE onset. However, the most accurate threshold for predicting ATE was CHADS2 score of 4 or higher. Using a multivariate analysis, only patient's history of stroke was associated with ATE onset (OR, 9.2 [2.4; 35]; P = .001). CONCLUSION: CHADS2 and CHA2DS2-VASc scores are predictive of SVA-related thromboembolism in the critically ill patient.