[Management of critically ill nontrauma patients in a nonuniversity emergency department]. / Nichttraumatologisches Schockraummanagement in einer nichtuniversitären Notaufnahme.

Purpose: Today there exists only limited knowledge regarding the care of critically ill nontrauma (CINT) patients in the resuscitation room (RR) in Germany. The goal of this observational study was to describe the management of CINT patients in the RR of a nonuniversity emergency department. Methods: Data of adult nontrauma patients in the RR were prospectively collected in this study from 26 January 2019 to 18 May 2021 using the OBSERvE­2 evaluation protocol. Results: In all, 213 patients were included in the study (age: 70 ± 15 years, 55% male; admission to the RR by emergency medical service 93%). 28% were brought in after out-of-hospital cardiac arrest. Leading admission causes were C (47%) and B problems (39%). Diagnoses at the end of RR treatment were 30% pulmonary and 26% cardiovascular diseases without myocardial infarction as well as pulmonary embolism (8% and 5%, respectively). Measures performed were airway protection (20%), invasive (46%) and noninvasive ventilation (25%), cardiopulmonary resuscitation (13%), catecholamine therapy (34%), emergency ultrasound (62%). The initial treatment lasted for 41 ± 22 min. Computed tomography was subsequently performed in 51%. On average 4-5 persons were involved in the treatment during the RR period. In total, 9% of the patients died during RR treatment and 40% in the hospital. Conclusion: Patients in a nonuniversity nontrauma RR are resource-intensive and have a high in-hospital lethality. RR care can be completed within 60 min. In order to achieve better comparability between patient populations of different locations, it is necessary to uniformly define admission criteria for the nontrauma resuscitation room.

Preexisting autoantibodies as predictor of immune related adverse events (irAEs) for advanced solid tumors treated with immune checkpoint inhibitors (ICIs).

INTRODUCTION: Immune checkpoint inhibitors (ICIs) are now standard of care in many cancers. They can generate immune-related adverse events (irAEs), but no biomarkers are available to identify patients who are more likely to develop irAEs. We assess the association between pre-existing autoantibodies and occurrence of irAEs. PATIENTS AND METHODS: We prospectively collected data from consecutive patients receiving ICIs for advanced cancers, in a single center between May 2015 and July 2021. Autoantibodies testing was performed before ICIs initiation including AntiNeutrophil Cytoplasmic Antibodies, Antinuclear Antibodies, Rheumatoid Factor anti-Thyroid Peroxidase and anti-Thyroglobulin. We analyzed the associations of pre-existing autoantibodies with onset, severity, time to irAEs and with survival outcomes. RESULTS: Of the 221 patients included, most had renal cell carcinoma (n = 99; 45%) or lung carcinoma (n = 90; 41%). Grade ≥2 irAEs were more frequent among patients with pre-existing autoantibodies: 64 (50%) vs. 20 (22%) patients (Odds-Ratio= 3.5 [95% CI=1.8-6.8]; p < 0.001) in the positive vs negative group, respectively. irAEs occurred earlier in the positive group with a median time interval between ICI initiation and irAE of 13 weeks (IQR = 8.8-21.6) vs. 28.5 weeks (IQR=10.6-55.1) in the negative group (p = 0.01). Twelve patients (9.4%) experienced multiple (≥2) irAEs in the positive group vs. 2 (2%) in the negative group (OR = 4.5 [95% CI: 0.98-36], p = 0.04). After a median follow-up of 25 months, median PFS and OS were significantly longer among patients experiencing irAE (p = 0.00034 and p = 0.016, respectively). CONCLUSION: The presence of pre-existing autoantibodies is significantly associated with the occurrence of grade ≥2 irAEs, with earlier and multiple irAEs in patients treated with ICIs.

Anaphylactic reaction after methylene blue-treated plasma transfusion.

Methylene blue-treated fresh-frozen plasma (MB-FFP) is mainly used in Europe. The advantage of the methylene blue system is that units can be treated individually. The combined action of methylene blue and illumination is a photodynamic process preventing viral RNA and DNA replication. We report the first immediate allergic hypersensitivity reaction to methylene blue-treated plasma transfusion. The clinical course and subsequent assessment of the allergic reaction, including skin tests and basophil activation test, confirmed methylene blue-induced IgE-mediated anaphylaxis. All immediate reactions after MB-FFP transfusion should be investigated to document the underlying mechanism.

Finite element modeling of the thoracic aorta: including aortic root motion to evaluate the risk of aortic dissection.

OBJECTIVE: We propose that the aortic root motion plays an important role in aortic dissection. METHODS AND RESULTS: A finite element model of the aortic root, arch and branches of the arch was built to assess the influence of aortic root displacement and pressure on the aortic wall stress. The largest stress increase due to aortic root displacement was found at approximately 2 cm above the top of the aortic valve. There, the longitudinal stress increased by 50% to 0.32 MPa when 8.9 mm axial displacement was applied in addition to 120 mmHg luminal pressure. A similar result was observed when the pressure load was increased to 180 mmHg without axial displacement. CONCLUSIONS: Both aortic root displacement and hypertension significantly increase the longitudinal stress in the ascending aorta, which could play a decisive role in the development of various aortic pathologies, including aortic dissection.

[Voriconazole photosensitivity: 7 cases]. / Photosensibilisation au voriconazole: 7 cas.

BACKGROUND: Voriconazole is a new second-generation fluconazole-derived triazole. With greater potency against susceptible species and a broader spectrum of activity than fluconazole, it is the treatment of choice for invasive pulmonary aspergillosis and other fungal infections (Fusarium, Scedosporium/Pseudalleschezria) is indicated in a visit Candida infections refractory to fluconazole. We describe 7 cases of photosensitivity during treatment with voriconazole in a setting of immunodepression. CASE REPORTS: The patients comprised 5 women and 2 men with a mean age of 38 years (17-67 years). Five had undergone pulmonary transplantation for mucoviscidosis, one had undergone kidney transplantation for lupus nephroangiosclerosis and one was on long-term systemic steroid treatment for Sjögren's syndrome. All patients had very severe immunosuppression and were receiving voriconazole for pulmonary aspergillosis (6 cases) or Scedosporium infection (1 case). Photosensitization appeared within 5 weeks to 14 months after the start of treatment, and in all cases followed exposure to sun, occasionally at low levels. In all cases, cutaneous lesions rapidly disappeared on discontinuation of treatment. DISCUSSION: There have been reports in the literature, although rare, of photosensitivity with voriconazole. Patients must be informed of the possibility of this adverse effect and sun protection must be recommended when voriconazole is prescribed, particularly during periods of intensive exposure.

Diagnostic score for heparin-induced thrombocytopenia after cardiopulmonary bypass.

Heparin-induced thrombocytopenia (HIT) occurs in nearly 3% of patients treated with heparin after cardiopulmonary bypass (CPB). HIT carries a risk of severe thrombotic complications, and must be diagnosed rapidly. To identify simple criteria for estimating the probability of HIT after CPB, we retrospectively analyzed the files of 84 patients with suspected HIT after CPB and we analyzed the usefulness of several variables collected at the time of HIT suspicion to estimate HIT probability. HIT was confirmed in 35 cases and ruled out in 49 cases, on the basis of a platelet increment after heparin withdrawal, detection of heparin-dependent antibodies, and absence of other clear cause of thrombocytopenia. A biphasic platelet count from CPB to the first day of suspected HIT, an interval of >/= 5 days from CPB to the first day of suspected HIT, and a CPB duration of

[Drug-induced fever: a diagnosis to remember]. / Fièvre médicamenteuse: un diagnostic à ne pas oublier.

Drug fever (DF) is a febrile reaction induced by a drug without additional clinical features like skin eruption. This adverse drug reaction is probably common but under diagnosed. While its outcome is generally favourable, DF generates unnecessary diagnostic procedures as well as hospitalisations or hospitalisation prolongations. Clinical presentation and biological findings are not specific. Fever is generally well tolerated but may be accompanied by general symptoms mimicking sepsis. Moderate biological disorders could be expected, including elevation or decrease in white blood cell count, eosinophilia, liver cytolysis, and increased C-reactive protein. An infection should be systematically ruled out. Clinical or biological signs of severity should question DF diagnosis. When DF is suspected, the involved drug(s) should be stopped after a reliable assessment of imputability. Antibiotics represent the most often implicated drugs. Fever disappearance after discontinuing the suspected drug is the cornerstone of DF diagnosis. Before stopping the administration of the suspected drug(s), a risk/benefit ratio assessment is necessary. Consistently, it may be complicated to stop an antimicrobial drug when treating an infection or an immunosuppressive drug if required.

[Rifampin-induced severe aseptic meningitis]. / Méningite aseptique sévère induite par la rifampicine.

We report the first case of acute drug-induced aseptic meningitis (DIAM) due to rifampin in a young female with systemic lupus erythematosus (SLE). DIAM is uncommon and its diagnosis is often difficult. This type of drug hypersensitivity is more frequently observed in patients with a history of auto-immune disease, particularly SLE. The major categories of causative agents are: nonsteroidal anti-inflammatory drugs, antimicrobials, intravenous immunoglobulins and biotherapies.

Neuromuscular painful disorders: a rare side effect of voriconazole in lung transplant patients under tacrolimus.

Voriconazole is an anti-fungal agent active against Aspergillus infection that is used for prophylaxis and curative treatment in lung transplant patients. We present nine cases of painful neuromuscular disorders, an unusual and rare side effect of high-dose voriconazole in association with tacrolimus.

Is there any impact of the shape of aortic end-hole cannula on stroke occurrence? clinical evaluation of straight and bent-tip aortic cannulae.

OBJECTIVE: To compare the impact of straight and bent-tip aortic cannulae on stroke occurrence, location, and severity. METHODS: Prospective data were collected on 8,129 patients (coronary artery bypass grafting (CABG) and/or valvular surgery). 'Bent-tip' aortic cannulae were used in 15.6% of cases and 'straight' end-hole cannulae in 84.4% of cases. RESULTS: There were a total of 137 strokes: right anterior 52, left anterior 39, bilateral 23, posterior 18, and location not established 5. With the use of bent-tip cannulae, the incidence of strokes was 0.9% versus 1.8% with straight cannulae (chi2, p = 0.026). Bilateral and posterior strokes occurred more often with the use of straight cannulae (chi2, p = 0.015). Straight cannulae also related to the severity of strokes (chi2, p = 0.003). CONCLUSIONS: There is an influence of the type of cannula on the occurrence, location, and severity of strokes. Straight cannulae cause significantly more often and more severe bilateral and posterior strokes than bent-tip cannulae.