[Outbreak of influenza pandemic virus A(H1N1) 2009 infections in the Emergency Department, Saint-Pierre, Réunion Island, July-September 2009]. / Caractéristiques des syndromes grippaux pris en charge aux urgences du centre hospitalier régional de Saint-Pierre, île de la Réunion, au cours de l'épidémie à virus pandémique A(H1N1) 2009 (juillet-septembre 2009).

A new H1N1 virus originating from swine recently emerged as the first influenza pandemic of the 21st century. On July 3, 2009, this new influenza A(H1N1) virus (S-OIV) of swine origins was identified in Réunion Island, a French overseas department located in the southern hemisphere. The present study describes the characteristics of the epidemic from July 3 to September 30, 2009. Among the 479 patients included in our study (236 males, 37.3 ± 19.0 years), 255 (53.2%) were reported to have comorbidities or risk factors (RF) for complications. Complications occurred in 160 patients (33.4%). The most common complications were bronchial hyperreactivity (52.7%), pneumonia (32.1%), and decompensation caused by comorbidity (17.9%). 111 patients (23.2%) required hospitalization. Patients aged 65 and over, accounted for 11.9% of all patients, 32.4% of hospitalized patients and 22.5% of complicated S-OIV infections. Regardless of age, comorbidity and/or RF were reported in 80.0% of complicated S-OIV infections and 91.0% of hospitalized patients. Recommendations for surveillance, prevention and policy for persons with RF, particularly respiratory disease, are justified. However, the absence of risk factors did not prevent the occurrence of complications, present in 14.3% of the cases.

Preliminary analysis of the pandemic H1N1 influenza on Reunion Island (Indian Ocean): surveillance trends (July to mid-September 2009).

First infections with the 2009 pandemic H1N1 influenza virus were identified on Reunion Island in July 2009. By the end of July, sustained community transmission of the virus was established. Pandemic H1N1 influenza activity peaked during week 35 (24 to 30 August), five weeks after the beginning of the epidemic and has been declining since week 36. We report preliminary epidemiological characteristics of the pandemic on Reunion Island in 2009 until week 37 ending September 13.

[Skin and mucosal manifestations of chikungunya virus infection in adults in Reunion Island]. / Manifestations cutanéo-muqueuses de l'infection par le virus chikungunya chez l'adulte à la Réunion.

Numerous skin and mucosal manifestations were observed during the 2005-2006 chikungunya epidemic in Reunion Island. A prospective study was carried out in a consecutive series of 212 patients treated for chikungunya at the emergency unit of the Saint-Pierre Hospital in Reunion Island from March 8 to April 27, 2006. Diagnosis of chikungunya was suspected in patients with fever and joint pain and confirmed by RT-PCR and/or serology (IgM). Skin involvement was observed in 50% of patients. It consisted of exanthema with patches of healthy skin mainly on the trunk and limbs that sometimes displayed diffuse, congestive and even edematous features. Itching was reported in some cases (19.3%) and was sometimes isolated. Peeling of the skin was observed in a few cases but remained uncommon in adults. Outcome was rapidly favorable in most cases sometimes with scaling or persistence of dyschromic patches. These findings suggest that chikungunya should be suspected in subjects presenting a febrile rash while in an endemic areas or after returning from a tropical zone.

Acquired hemophilia due to factor VIII inhibitors in 34 patients.

BACKGROUND: Acquired hemophilia is a rare disease caused by the development of auto-antibodies against factor VIII. SUBJECTS AND METHODS: We studied the characteristics and outcomes of 34 patients (19 women and 15 men) with acquired hemophilia from 1980 to 1997. RESULTS: The mean age of the patients was 61 years (range, 22-93 years). An underlying disease was observed in 18 (53%) patients: 5 patients had cancer, 4 an autoimmune disorder, 2 a dermatologic disorder, 3 asthma, 3 were postpartum, and 1 had an adverse reaction to ampicillin. Factor VIII level was <5% in 30 (90%) patients; factor VIII antibodies were elevated (>10 Bethesda units) in 23 (69%) patients. Bleeding requiring transfusions was reported in 25 (75%) patients. Human factor VIII was given to 14 patients and porcine factor VIII to 5. Six patients received prothrombin complex concentrates and one desmopressin. Several immunosuppressive treatments were used, mainly corticosteroids, cyclophosphamide, and intravenous immunoglobulin. Bleeding stopped in all but one patient within 2 weeks. Most patients achieved complete remission, although two relapses were observed subsequently. CONCLUSION: This large study helps to clarify the presentation and clinical course of acquired hemophilia. Prospective studies are needed to determine the efficacy of treatment.

Mechanical ventilation for Pneumocystis carinii pneumonia in patients with the acquired immunodeficiency syndrome. Is the prognosis really improved?

The mortality rate among patients with human immunodeficiency virus (HIV) requiring mechanical ventilation (MV) for acute respiratory failure (ARF) secondary to Pneumocystis carinii pneumonia (PCP) is still a matter of discussion. For some authors, it is in the 50 percent range, while for others the prognosis is grim, with virtually no survivors. The aim of this retrospective study conducted between January 1987 and January 1992 was to analyze the outcome of such patients. We studied 33 patients, 29 men and 4 women (38.6 +/- 9.9 years, 21 homosexuals, 8 intravenous drug users, 3 transfusion related, 1 heterosexual) infected by HIV for at least 19.7 +/- 21.6 months. It was the first PCP episode in all but 2 patients and the diagnosis was made by bronchoalveolar lavage (n = 32) or lung biopsy specimen (n = 1). Only three patients were receiving primary prophylaxis for PCP (trimethoprim-sulfamethoxazole [TMP-SMZ], n = 2; pentamidine, n = 1). Pneumocystis carinii pneumonia was the first manifestation of AIDS in nine patients. The duration of symptoms prior to treatment was 19.6 +/- 11.3 days. At the time of hospital admission, laboratory findings were as follows: PaO2 = 40.7 +/- 7.8 mm Hg on room air; serum LDH = 1,172 +/- 792 IU/L; T4 cell count = 60.2 +/- 67/mm3. Mechanical ventilation was always required for ARF, which was never induced by bronchoscopy. The interval between treatment and MV was 8.1 +/- 6.5 days and the duration of MV was 11.4 +/- 9.9 days. The patients were classified into 3 groups on the basis of the duration and type of treatment before MV, as follows: group 1, n = 10: TMP-SMZ (20-100 mg/kg) IV and methylprednisolone (MP) < 5 days before MV; group 2, n = 4: TMP-SMZ > or = 5 days and MP < 5 days; group 3, n = 19: TMP-SMZ and MP > or = 5 days before MV. (The MP dose was as follows: 240 mg/d once a day from day 1 to day 3; 120 mg/d from day 4 to day 6; and 60 mg/d from day 7 to day 9.) Despite MV, TMP-SMZ, and MP, death secondary to PCP-related ARF occurred in 81.9 percent of patients, 20 +/- 4.8 days after the beginning of treatment and 11.4 +/- 9.9 days after the beginning of MV. Six patients survived, five in group 1 and one in group 3.(ABSTRACT TRUNCATED AT 400 WORDS)

Prospective evaluation of self-extubations in a medical intensive care unit.

OBJECTIVE: To evaluate the incidence, associated factors and gravity of self-extubations. DESIGN: Prospective study about all patients intubated over an 8 month period. SETTING: A medical intensive care unit of a University Hospital. PATIENTS: Patients were divided into two groups: self-extubated and those that did not. The self-extubations were separated into deliberate acts by the patients and accidental. RESULTS: 24 of the 197 patients included presented a total of 27 extubations (12%). There were 21 deliberate incidents and 6 accidental. The only differences between the cases and the rest of the population were a higher mean age (67 vs 59 years) and a larger proportion of chronic respiratory failure (66% versus 35%). Reintubation was necessary in 20 cases (74%) within 30 min in 16 cases. The main indication for reintubation was acute respiratory distress (90%). Reintubation was associated with one death. CONCLUSION: Self-extubation is a frequent and serious complication of mechanical ventilation. Deliberate self-extubation, the most frequent type of incident could possibly be reduced by better sedation of agitated patients and accidental self-extubation by better training of the nursing staff.

Biochemical assessment of nutritional status in patients with chronic obstructive pulmonary disease and acute respiratory failure on admission to an intensive care unit.

Although chronic obstructive pulmonary disease (COPD) is associated with weight loss and malnutrition, there is a paucity of relevant data on COPD patients with acute respiratory failure (ARF). We studied 30 consecutive patients on the day of admission to our intensive care unit for ARF. In addition to a clinical work-up, the following biochemical parameters were determined: markers of nutritional status (albumin - ALB, transferrin - TRF, transthyretin - TTR, retinol binding protein - RBP, fibronectin), inflammation (C-reactive protein - CRP, alpha(1) glycoprotein acid - alpha(1)GPA) and catabolism (plasma phenylalanine - PHE, urinary 3-methylhistidine - 3-MH). Values were expressed as mean +/- SD and compared to those of 10 healthy subjects matched for age. COPD-ARF patients had a poor protein status (ALB = 30 +/- 5 vs 42 +/- 3 g.l(-1); TTR = 118 +/- 75 vs 251 +/- 43 mg.l(-1); RBP = 23 +/- 12 vs 46 +/- 8 mg.l(-1); p < 0.001), were hypercatabolic (3-MH Cr = 31 +/- 12 vs 22 +/- 7 mumol.mmol Cr (-1); PHE = 62 +/- 27 vs 46 +/- 10 mumol.l(-1); p < 0.001) and inflamed (CRP = 68 +/- 50 vs 12 +/- 5 mg.l(-1); alpha(1)GPA = 1.2 +/- 0.4 vs 0.5 +/- 0.1 g.l(-1); p < 0.001). Severity of the disease correlated with short half-life proteins and protein catabolism markers but not with inflammation markers. Considering ALB, TTR, RBP, the 3- MH Cr ratio and PHE values, the 30 COPD patients fell into 3 groups: chronic malnutrition (n = 7), acute malnutrition (n = 2), and acute + chronic malnutrition (n = 18). 3 patients had normal nutritional status. We conclude that an assessment of nutritional status at admission to intensive care units could contribute towards a rapid formulation of specific nutritional therapy.

[Inhibitors of factor VIIIc and pregnancy. Review of the literature]. / Les inhibiteurs du facteur VIIIc et grossesse. Revue de la littérature.

Circulating anticoagulants directed against factor VIII coagulant activity are very rarely encountered. Eighteen per cent of them have been described in the peripartum period of primiparae aged 28 years on average. The clinical signs are the same as those of constitutional haemophilia, but they differ in frequency. The most common of these signs are haematoma, ecchymoses and haematuria. The diagnosis is confirmed by prolongation of clotting time alone, presence of an anticoagulant in blood and specific assay of the deficient coagulant factor. These inhibitors are usually immunoglobulins of the IgG type. The cause and pathogenesis of the disease are unknown. Treatment consists of administering coagulant factors in haemorrhagic periods and immuno-suppressive therapy. Spontaneous remissions are frequent.

[Acidoketosis in a chronic alcoholic woman]. / Acidocétose chez une alcoolique chronique.

A 37-year-old chronic alcoholic female was admitted with epigastric pain, complete anorexia, vomiting and diarrhoea. She was dehydrated, and had polypnoea. Laboratory investigations revealed severe metabolic acidosis (pH 7.14) with a major anion gap (37.4 mmol.l-1), and ketone bodies in blood and urine. Blood glucose concentration was 6.1 mmol.l-1, there was no glycosuria. Rehydration (2 l.day-1 of 5% glucose) together with sodium bicarbonate (500 ml of 1.4% sodium bicarbonate over the first four hours) normalized the pH (7.37). The ketone bodies disappeared on the following day. During the acute illness, were found high blood levels of glucagon and low levels of insulin. The diagnosis of alcoholic ketoacidosis, the pathogenesis of which remains unknown, is discussed.

[Efficacy and tolerance of Elohes in plasma exchanges]. / Efficacité et tolérance de l'Elohes dans les échanges plasmatiques.

This study aimed to compare two plasma substitution regimens used during plasma exchanges (PE). It was a prospective cross-over randomized trial. Each patient (n = 12) had two PE at a 48 h interval. During one PE, only albumin was administered (PEA), and during the other one, equal volumes of albumin and low molecular weight hydroxyethylstarch (HES) (Elohes) were given (PEA+E). The order in which these different protocols were used was random. Plasma was separated by filtration, and the total volume extracted was one and a half the plasma volume. The parameters recorded every 15 min until 1 h after the end of PE, were heart rate, blood pressure and central venous pressure (CVP). Plasma volume, calculated from the mean body haematocrit and blood volume, was measured before and after PE. The clinical and biological tolerance of the rapid infusion of a large volume of HES was also assessed. PE characteristics were similar in both groups. For PEA and PEA+E, PE lasted 152 +/- 21 min and 154 +/- 25 min; the plasma volume extracted was 3,907 +/- 772 ml and 3,933 +/- 717 ml; the volume of plasma substitute infused was 4,097 +/- 617 ml and 3,933 +/- 717 ml, respectively. As haemodynamic and biochemical values were not significantly different in both groups, they were pooled together irrespective of the order of PE.(ABSTRACT TRUNCATED AT 250 WORDS)

[Acquired autoantibodies directed against human factor VIIIc. Treatment of 2 hemorrhagic accidents with porcine factor VIIIc]. / Auto-anticorps acquis contre le facteur VIIIc humain. Traitement de deux accidents hémorragiques par le facteur VIIIc porcin.

The emergence of an autoantibody directed against factor VIII may be responsible for severe, life-threatening haemorrhages. This rare disease is usually idiopathic, but it may be consecutive to an autoimmune disease or to the absorption of certain drugs such as penicillin. The diagnosis rests on the finding of a prolonged activated thromboplastin time with presence of a circulating anticoagulant and deep fall in factor VIII level. Two cases of severe haemorrhage successfully treated with porcine factor VIIIc are reported. The first case concerned an 80-year old woman presenting with a large haematoma of the thigh uncontrolled by injections of human factor VIIIc. The second case was that of a 24-year old woman in a state of shock due to a pleural blood effusion that occurred during heparin treatment of cerebral thrombophlebitis, combined with penicillin treatment of bronchial superinfection. In both cases the high-titer autoantibody to the human factor VIIIc did not, or little, cross with porcine factor VIIIc. Factor VIII rose after the first injection of the porcine factor, and the haemorrhage was rapidly controlled. In both cases, the autoantibody disappeared within a few months, either spontaneously or after treatment with immunosuppressants.

[Hypokalemia in massive chloroquine poisoning. 2 cases]. / Hypokaliémie au cours d'intoxications massives par la chloroquine. Deux cas.

Two cases of hypokalemia which was deep (1.1 mmol/l), symptomatic and protracted were observed during the early course of acute massive chloroquine intoxication. Biochemical data suggest that the mechanism of hypokalemia in such cases is intracellular transport.

[Voluntary drug poisoning cases admitted to an emergency care unit]. / Intoxications médicamenteuses volontaires reçues dans un service d'accueil des urgences.

OBJECTIVES: The aim of this study was to ascertain the specific nature of voluntary drug intoxications seen in emergency wards receiving adult patients. METHODS: From July 1992 to June 1993, all patients presenting at the emergency room with voluntary drug intoxication were assessed retrospectively. There were 727 patients (482 females and 245 males, mean age 33.3 +/- 12 years, age range 15-92) admitted for 804 episodes of voluntary drug intoxication. RESULTS: A past history of psychiatric problems or drug abuse was found in 42.8 and 9.1% of the patients respectively. The time laps between ingestion and consultation was noted for 43% (5 h 30 +/- 9 h, range 15-4320 min). The drug ingested was identified in 89% of the cases and 1.7 drugs were ingested per episode (range 1-8). Generally, only 1 (52%) or 2 (21%) drugs were ingested. Nonbarbituric psychotropic agents were ingested in 79.7% of the cases. Alcohol had also been consumed in 36.5% of the cases. Treatment was gastric lavage in 34.4%, activated carbon in 16.7%, flumazenil in 16.9%, naloxone and N-acetyl-cysteine in 3.4%. Twelve patients required intubation. Patients were admitted to a medical (n = 156) or psychiatric (n = 67) ward or an intensive care unit (n = 61). Nearly 25% of the patients left hospital either against medical advice or left without notice. CONCLUSION: Voluntary drug intoxications seen in emergency rooms require care by a well coordinated team of clinicians and psychiatrists.

[Poisoning with "poppers", a rare cause of methemoglobinemia observed in emergency cases]. / L'intoxication au "poppers", cause rare de méthémoglobinémie observée aux urgences.

BACKGROUND: Methemoglobulinemia should be entertained as a differential diagnosis in patients with cyanosis. Recently in France there has been an increase in the number of cases of acquired methemoglobulinemia due to inhalation of poppers. CASE REPORTS: Four patients were admitted to the emergency room of a Paris hospital in a state of unconsciousness with cyanosis. All four patients had inhaled poppers shortly before admission. The clinical course was rapidly favorable after intravenous infusion of methylene blue in 3 cases. DISCUSSION: Poppers are inorganic aliphatic nitrites used for their relaxing effect on smooth muscle and for their aphrodisiac effect. One poorly recognized effect is the development of methemoglobulinemia. Tissue hypoxia results because methemoglobulin cannot bind oxygen, leading to a brown or blue coloration of the blood. Methemoglobulin usually results from exposure to a wide variety of oxidizing compounds including certain drugs. Methylene blue is the specific treatment for symptomatic methemoglobulinemia. These four cases emphasize the toxic effect of products sold in sex shops and calls attention to the life-threatening risks involved.

[Enteral nutrition in patients with chronic obstructive bronchopathy treated by artificial ventilation. Effect of conventional feeding on anthropometric and biochemical parameters]. / Nutrition entérale chez le bronchopathe chronique obstructif soumis à une ventilation artificielle. Influence d'une alimentation conventionnelle sur les paramètres anthropométriques et biochimiques.

The influence of conventional gastric tube feeding on anthropometric and biochemical parameters was studied prospectively during 12 months in 14 patients with chronic obstructive lung disease put on mechanical ventilation for respiratory failure. The anthropometric parameters were: body weight, tricipital skin fold, brachial and brachial muscle circumferences. The biochemical parameters included albumin, transferrin, retinol binding protein, transthyretin, acid alpha-1-glycoprotein, C-reactive protein, fibronectin and amino acids in blood, and 3-methylhistidine in urine. Measurements were performed on inclusion, then every 3 days until D15. After 15 days of a nutrition bringing 28.8 +/- 8.9 calories/kg/day and 13.9 +/- 2.2 grams of nitrogen per day, no improvement in anthropometric parameters was observed. On D0, comparisons with healthy controls showed that visceral serum proteins levels were significantly lower and inflammatory proteins levels significantly higher (P < 0.05); the levels of protein metabolism markers were higher, but not significantly, and those of the principal glucose-forming amino acids were significantly lower (P < 0.01). On D15, comparisons with the initial values showed that the values of retinol binding protein and transthyretin were increased (P < 0.05 and 0.01 respectively), whereas the values of the other visceral proteins were little modified; yet their concentrations remained significantly lower than those found in controls, except for the retinol binding protein. Inflammatory proteins levels were high, with a significant (P = 0.05) difference for the acid alpha-1-glycoprotein, and the patients remained in slight catabolism while their nitrogen balance was positive. These results should encourage to carry out studies on the qualitative composition of artificial nutrition in order to optimize its effectiveness in the treatment of these patients.

[Access of torsades de pointes in Legionnaires' disease: an uncommon adverse effect of erythromycin]. / Accès de torsades de pointes au cours d'une maladie des légionnaires:un accident exceptionnel de l'érythromycine.

We report the case of a 77-year-old man with legionnaires's disease who, immediately after an intravenous infusion of one gram of erythromycin presented with wave burst arrhythmia with widening of the QT space. The blood level of erythromycin at the time of this adverse reaction was the same as the peak observed in young subjects after intravenous administration of this drug. Fourteen similar cases were found in the literature. In vitro and in vivo studies have shown that erythromycin may exert on the cardiac muscle fibres an electrophysiological effect similar to that of class I antiarrhythmic agents.

[Interleukins and TNF in septic shock]. / Interleukines et TNF dans le choc septique.

Tumor necrosis factor alpha (TNF alpha) and interleukins (IL) are the principal cytokines involved in the clinical and biological manifestations of septic shock. Their secretion are triggered mainly by endotoxin, but products of Gram positive cocci as well as of virus or of parasites are equally effective. Cytokines represent a normal protective defense against infection, but an excessive production have toxic effects. In experimental models of endotoxinemia, TNF alpha is the first cytokine produced, then IL-1 and IL-6. Other inflammatory mediators are secreted later. Thus it seems logical to try to modulate cytokine production or actions. However, several questions remains since experimental data are sometimes not applicable too human diseases, cytokines are organised in a network with several interaction. It is too early to propose routine anti-cytokines drugs in septic shock.

[Non-lactic metabolic acidosis]. / Acidoses métaboliques non lactiques.

The definition of metabolic acidosis (MA) is a primary decrease in plasma bicarbonate concentration. The visceral consequences are largely dependent on the degree of acidosis and the rapidity of its onset; they have been studied mainly in animal studies and therefore, extrapolation to the clinical situation should be cautious. The MA can be classified in two groups according to whether the anionic serum gap is increased or normal (hyperchloremic acidosis). The etiologies of the first group are lactic acidosis, the cetoacidoses and renal failure. The hyperchloremic acidoses usually result from gastro-intestinal bicarbonate losses; the biochemical diagnosis of rarer causes of hyperchloremic acidosis is facilitated by measuring the serum potassium, urinary pH and the urinary anionic gap. Although all causes of MA must be treated, the use of bicarbonate should be discussed in each individual case.

A review of the dynamics and severity of the pandemic A(H1N1) influenza virus on Réunion island, 2009.

On Reunion Island, in response to the threat of emergence of the pandemic influenza A(H1N1)2009 virus, we implemented enhanced influenza surveillance from May 2009 onwards in order to detect the introduction of pandemic H1N1 influenza and to monitor its spread and impact on public health. The first 2009 pandemic influenza A(H1N1) virus was identified in Réunion on July 5, 2009, in a traveller returning from Australia; seasonal influenza B virus activity had already been detected. By the end of July, a sustained community pandemic virus transmission had been established. Pandemic H1N1 influenza activity peaked during week 35 (24-30 August 2009), 4 weeks after the beginning of the epidemic. The epidemic ended on week 38 and had lasted 9 weeks. During these 9 weeks, an estimated 66 915 persons who consulted a physician could have been infected by the influenza A(H1N1)2009 virus, giving a cumulative attack rate for consultants of 8.26%. Taking into account the people who did not consult, the total number of infected persons reached 104 067, giving a cumulative attack rate for symptomatics of 12.85%. The crude fatality rate (CFR) for influenza A(H1N1)2009 and the CFR for acute respiratory infection was 0.7/10 000 cases. Our data show that influenza pandemic did not have a health impact on overall mortality on Réunion Island. These findings demonstrate the value of an integrated epidemiological, virological and hospital surveillance programme to monitor the scope of an epidemic, identify circulating strains and provide some guidance to public health control measures.