Time-dependent analysis of extra length of stay and mortality due to ventilator-associated pneumonia in intensive-care units of ten limited-resources countries: findings of the International Nosocomial Infection Control Consortium (INICC).

Ventilator-associated pneumonias (VAPs) are a worldwide problem that significantly increases patient morbidity, mortality, and length of stay (LoS), and their effects should be estimated to account for the timing of infection. The purpose of the study was to estimate extra LoS and mortality in an intensive-care unit (ICU) due to a VAP in a cohort of 69,248 admissions followed for 283,069 days in ICUs from 10 countries. Data were arranged according to the multi-state format. Extra LoS and increased risk of death were estimated independently in each country, and their results were combined using a random-effects meta-analysis. VAP prolonged LoS by an average of 2·03 days (95% CI 1·52-2·54 days), and increased the risk of death by 14% (95% CI 2-27). The increased risk of death due to VAP was explained by confounding with patient morbidity.

[Effects of corticosteroids on adults with tuberculous meningitis admitted to intensive care unit: a propensity score analysis]. / Effets de la corticothérapie chez les adultes admis en réanimation pour méningite tuberculeuse: analyse par le score de propension.

INTRODUCTION: The beneficial effect of corticosteroids has been well established, particularly in patients free of infection with the human immunodeficiency virus. In intensive care units, the high risks of infection to which patients are exposed specifically could offset the neurological benefit of corticosteroids. The purpose of the study was to assess the effects of corticosteroids in adult patients with tuberculous meningitis admitted to intensive care unit. METHODS: Retrospective cohort study including all adult patients admitted to intensive care unit for tuberculous meningitis between January 1993 and December 2005. A propensity score case matching was performed using a multivariable logistic regression model, and matched pairs were examined for baseline characteristics and outcome by using conditional regression model. A multivariate Cox's proportional hazard model was used to assess the effects of corticosteroids in all patients adjusting for propensity score. The primary outcome was mortality at 60 days and the secondary outcome was the density of incidence of nosocomial infections. RESULTS: Two hundred and seventy patients were included. The mean age was 38+/-17 years, and the Glasgow coma scale was 12+/-3. The overall mortality was 43.3%. Ninety-four patients who had received corticosteroids were matched to 94 patients untreated with corticosteroids by the propensity score. The baseline characteristics were similar in the two groups except for hydrocephalus, which was more frequent in the group corticosteroids. The mortality rate was 47.9% in group Corticosteroids and 52.1% in group No corticosteroids (P=0.77). The case fatality rate in stage III patients, according to the British Medical Research Council criteria, was 61.5% in the group Corticosteroids versus 74.1% in the group No corticosteroids (P=0.33). Nosocomial infections were observed in 19.1 by 1000 days patient in group Corticosteroids versus 16.1 by 1000 days patient in group No corticosteroids (P=0.4). The outcome in all patients after adjusting for propensity score showed the same results. CONCLUSION: This study found no significant improvement in survival in adult patients with tuberculous meningitis admitted to intensive care who received dexamethasone. However, the confidence interval was in accordance with the 0.78 relative risk estimated by the meta-analysis Cochrane version 2008. There was no significant difference for nosocomial infections between the group Corticosteroids and the group No corticosteroids. A probable lack of statistical power may explain these results.

Prognostic factors of acute aluminum phosphide poisoning.

BACKGROUND: In Morocco, acute aluminum phosphide poisoning (AAlPP) is a serious health care problem. It results in high mortality rate despite the progress of critical care. AIMS: The present paper aims at determining the characteristics of AAlPP and evaluating its severity factors. SETTING AND DESIGN: We studied consecutive patients of AAlPP admitted to the medical intensive care unit (ICU) (Ibn Sina Hospital, Rabat, Morocco) between January 1992 and December 2007. MATERIALS AND METHODS: Around 50 parameters were collected, and a comparison was made between survivor and nonsurvivor groups. STATISTICAL ANALYSIS: Data were analyzed using Fisher exact test, Mann-Whitney U test and Cox regression model. RESULTS: Forty-nine patients were enrolled: 31 females and 18 males; their average age was 26+/-11 years. The ingested dose of aluminum phosphide was 1.2+/-0.7 g. Self-poisoning was observed in 47 cases, and the median of delay before admission to the hospital was 5.3 hours (range, 2.9-10 hours). Glasgow coma scale was 14+/-2. Shock was reported in 42.6% of the patients. pH was 7.1+/-0.4, and bicarbonate concentration was 16.3+/-8.8 mmol/L. Electrocardiogram abnormalities were noted in 28 (57%) cases. The mortality rate was 49% (24 cases). The prognostic factors were APACHE II (P=0.01), low Glasgow coma scale (P=0.022), shock (P=0.0003), electrocardiogram abnormalities (P=0.015), acute renal failure (P=0.026), low prothrombin rate (P=0.020), hyperleukocytosis (P=0.004), use of vasoactive drugs (P<0.001), use of mechanical ventilation (P=0.003). Multivariate analysis by logistic regression revealed that mortality in AAlPP correlated with shock (RR=3.82; 95% CI=1.12-13.38; P=0.036) and altered consciousness (RR=3.26; 95% CI=1.18-8.99; P=0.022). CONCLUSION: AAlPP is responsible for a high mortality, which is primarily due to hemodynamic failure.

Myocardial lysis in a fetus induced by maternal paraphenylenediamine poisoning following an intentional ingestion to induce abortion.

The acute toxicity of paraphenylenediamine (PPD) has been associated with several histopathological changes. In humans, acute PPD poisoning is known to cause rhabdomyolisis and particularly myocardial lysis. However, its toxicity for the fetus has never been reported in the literature. We report a case of myocardial lysis in a fetus expelled by a 22-year-old mother after apparent ingestion of an unknown amount of PPD. The patient was admitted to our intensive care unit with acute onset of respiratory distress and rhabdomyolysis. The pelvic ultrasonography on admission showed a normally progressing pregnancy of 23-24 weeks. On day 9 post-ingestion, the patient spontaneously expelled a non-viable fetus. The fetal examination did not show any external or macroscopic abnormalities. However, the histopathological exam showed an important heart and lung congestion. There was also some interstitial edema and inflammation at the base of the lingua, in addition to a chorionic villus thrombosis and abruptio placentae. The histopathology of the myocardium showed lysis of the cardiac muscle. This observation suggests that the PPD was most likely responsible for the myocardial injury in the fetus.

[Evaluation of the reality of capillary glycemia measurement in an intensive care unit]. / Evaluation de la fiabilité de la mesure de la glycémie capillaire dans une unité de soins intensifs.

BACKGROUND: The usual glycemic supervision based on repeated measures of the capillary glycemia with the strip of which reliability can be taken at fault especially in critically ill patients. The objective of this work was to evaluate the reliability of capillary glycemia measurement in intensive care unit. MATERIAL AND METHODS: [corrected] The study was performed in a medical intensive care unit, during six months (July to December 2004). The capillary glycemias were carried out with only one blood glucose monitor and were compared with the referenced glycemias. The correlation between two methods was carried out by the parametric Pearson coefficient. The error percentage of the blood glucose monitor was calculated. The agreement of two methods was evaluated by Bland and Altman test. RESULTS: Were performed 245 glycemic pairs for 198 patients, their mean age was 42.6 +/- 14.6 years, 30(15%) among them were diabetics. The referenced glycemia was 8.7 +/- 5.5 mmol/L and the capillary glycemia was 8.3 +/- 4.6 mmol/L. The correlation coefficient was 0.97 (p<0.001); 56 percent of the values had an error percentage lower than 10, 27 percent between 10 and 20%, and there were 17 percent discordant values with an error percentage higher than 20. The method of Bland and Altman objectived a skew of 0.40 mmol/L and a bad precision of +/- 2.90 mmol/L. CONCLUSION: The reliability of capillary glycemias was not satisfactory with bad precision and high percentage of discordance. The capillary glycemias must be interpreted with precaution in intensive care unit.

[Acute pancreatitis revealing a systemic lupus erythematous]. / Pancréatite aiguë révélatrice d'un lupus érythémateux aigu disséminé.

INTRODUCTION: Acute pancreatitis is rarely seen in systemic lupus erythematous. CASE REPORT: A 28-year-old woman without significant past medical history, was hospitalized for sepsis and diagnosed with acute pancreatitis, which was found to be the initial presentation of a newly diagnosed systemic lupus erythematous. DISCUSSION: Acute pancreatitis as an initial presentation of systemic lupus erythematous is rare and is reported in only 10 cases in the literature. Multiple factors are involved in the pathogenesis. The role of corticosteroids in its apparition or resolution is still a subject of controversy.

[Severity factors of aluminium phosphide poisoning (Phostoxin)]. / Facteurs de gravité de l'intoxication aiguë au phosphure d'aluminium (Phostoxin).

OBJECTIVES: To determine characteristics of acute aluminum phosphide poisoning (AAlPP) and to evaluate its severity factors. DESIGN STUDY: Retrospective cohort study. PATIENTS AND METHODS: Consecutive cases of AAlPP admitted in medical ICU (Hospital Avicenne, Rabat, Morocco) between January 1992 and December 2002 were studied. AAlPP was identified by history, symptoms and toxicological results. Almost 50 parameters have been collected and compared between survivors and non-survivors groups. Data were analyzed using Fisher exact test and Mann-Whitney test. RESULTS: Twenty-eight patients were enrolled: 17 female and 11 male, average age = 24+/-11 years, SAPS II = 24.4+/-14.5. The ingested dose was 3.3+/-1.8 g. The self-poisoning was observed in 27 cases and delay before hospital admission was 11+/-13 hours. Mean Glasgow coma scale was 14+/-2. Shock was found in 22 (79%) cases. Average pH was 7.1+/-0.4 and bicarbonate concentration was 16.3+/-8.8 mmol/l. The ECG abnormalities were noted in 20 (72%) cases. The average mortality rate was 61%. The prognostic factors were SAPS II (p = 0.031), Apache II (p = 0.037), shock (p = 0.022), ECG abnormalities (p = 0.05), use of vasoactive drugs (p = 0.05) and use of mechanical ventilation (p = 0.003). CONCLUSION: AAlPP induced a significantly high mortality and haemodynamic disturbances were a risk factor of poor outcome.

End-stage renal disease in Tunisian infants: Etiology and outcome.

End stage renal disease (ESRD) in infants has particular features in terms of etiologies and therapeutic modalities. The aim of our study is to describe the etiologies and the ESRD outcomes among Tunisian infants. This retrospective study was conducted over 15 years (from January 1998 to December 31, 2013) in the Pediatric Department at Charles Nicolle Hospital. In total, 157 pediatric patients had ESRD. The mean incidence was 4.25 million children. The study involved 24 infants; the sex ratio was equal to 2. The mean age at diagnosis of ESRD was 8 months (range, 1-21 months). Growth retardation was noticed in 14 patients. The main causes were Congenital Anomalies of the Kidneys and Urinary Tract (9 infants) and hereditary renal disease (9 infants). All patients were treated with peritoneal dialysis; 16 infants presented peritonitis. Mortality rate was about 28%. The leading causes of death were cardiovascular diseases and infections.

[Incidence, causes and prognostic factors of hyponatremia in intensive care]. / Incidence, étiologies et facteurs pronostiques de l'hyponatrémie en réanimation.

PURPOSE: The incidence of hyponatremia is unknown, their causes are multiple. The higher mortality, especially in intensive care units, is currently unexplained. The objective of this article is to evaluate the incidence of hyponatremia, to assess their causes and to identify predictors of prognosis in intensive care units. METHODS: We included retrospectively all patients admitted at department of medical intensive care unit between January 1996 and February 2001, who presented at the admission, an hyponatremia (< 130 mmol/l). We excluded all patients who presented a hospital acquired hyponatremia, or hyponatremia associated with hyperglycemia > 13 mmol/l or with mannitol administration. Data were analysed by univariate methods, then by multivariate analysis. RESULTS: During the study period, 300 patients were identified among 2188: the incidence was 13.7% with 95% confidence interval (95% CI) between 9.8 % and 16.7%. Hypovolemic hyponatremia was observed in 25.7%, hypervolemic in 23.7% and normovolemic in 50.6%. In-hospital mortality was 37.7% (95% CI: 31.8% - 42.3%). Nine data were significantly associated with higher mortality in univariate analysis, but only 5 were identified as independant predictors of hospital mortality in multivariate analysis: hyponatremia < 125 mmol/l with a significant relative risk (RR) (RR = 2.10; 95% CI: 1.43-3.08; p < 0.001), Glasgow score < 9 (RR = 2.66; 95% CI: 1.25-5.66; p = 0.01), Glasgow score between 9 and 14 (RR = 1.94; 95% CI: 1.31-2.88; p < 0.001), shock (RR = 1.80; 95% CI: 1.10-3.05; p = 0.02) and blood urea concentration > 10 mmol/l (RR = 1.59; 95% CI : 1.08-2.34; p = 0.02). CONCLUSION: The frequency of hyponatremia is high; the normovolemic type represented 50%. Mortality is linked, in greater part, to organs dysfunction, but the severity of hyponatremia remained a significant predictor of mortality.

[Comparative efficiency of nebulized adrenaline and salbutamol in severe acute asthma. A randomized, controlled prospective study]. / Efficacité comparée de l'adrénaline et du salbutamol en nébulisation dans l'asthme aigu grave. Essai clinique contrôlé prospectif randomisé.

OBJECTIVE: To compare nebulized salbutamol and nebulized adrenaline in acute severe asthma (ASA). STUDY DESIGN: Prospective controlled study. PATIENTS AND METHODS: October 1998 at May 99, 44 patients (31 women and 13 men, 35 +/- 11 yrs) with ASA (defined as peak expiratory flow rate (PEF) < 150 l min-1 and normo- or hypercapnia) were randomized to receive either nebulized salbutamol (n = 22), 10 mg/h-1 during 2 h then 5 mg every 4 h or nebulized adrenaline (n = 22), 6 mg/h-1 during 2 h then 3 mg every 4 h. The efficacy was assessed by PEF, forced expiratory volume in one second (FEV1) and Fischl's score during eight hours and by arterial blood gases during the first hour. Side-effects were evaluated by heart rate, systolic blood pressure, serum potassium and blood glucose. Statistical tests: Wilcoxon, Fischer exact, ANOVA and Scheffe's test. RESULTS: Both groups were similar with respect to age, sex, severity, duration of asthma and length of crisis. With the two treatments, PEF increased significantly but no statistical difference were observed between the two groups during the eight hours: 117.7 +/- 41.6 l min-1 to 203.3 +/- 56.9 l min-1 in the salbutamol group; 116.4 +/- 36.8 l min-1 to 217.3 +/- 188.8 l min-1 in the adrenaline group; p = 0.77. FEV1, Fischl's score and arterial blood gases did not differ significantly between treatments at every time interval. There were no significant difference between the two groups in terms of side-effects. The intravenous way was necessary at 3 cases of the salbutamol group and 4 cases of adrenaline group (NS). CONCLUSION: The results suggest that nebulized adrenaline is as effective as nebulized salbutamol in the ASA without significant side-effects. The nebulization could reduce systemic effects of adrenaline.

[Left ventricular thrombus and myocarditis induced by paraphenylenediamine poisoning]. / Thrombus ventriculaire gauche et myocardite toxique induite par la paraphénylène diamine.

We showed that the paraphenylenediamine (PPD) poisoning caused myocarditis but there is no data on the echocardiographic features. We report a case of myocarditis induced by PPD poisoning with echographic data. After ingestion of 5 g of PPD, a 18-year-old woman was admitted to the hospital with asphyxia and rhabdomyolysis. An electrocardiogram showed ventricular extrasystoles and negative T waves. The serum concentration of CK was 28,020 UI l(-1) (iso-enzyme MB = 840 UI l(-1)). A transthoracic echocardiography showed significant left and right ventricular hypokinesis (shortening fraction = 20% and left ventricular ejection fraction = 35%) and a left ventricular apical thrombus. Anticoagulation treatment with heparin was initiated. A follow-up echocardiogram performed on the 15th day showed normalization of ventricular function and disappearance of the thrombus. No embolic event was noted. Echocardiography is indicated in the myocarditis induced by PPD poisoning to prove the ventricular function as well as the presence of a thrombus.

Psychological burden in inpatient relatives: the forgotten side of medical management.

BACKGROUND: The burden of the hospital experience is a broad issue that has been evaluated in a particular context of intensive care unit (ICU). It is likely, however, that the load is heavy on families even in other hospital wards and not just in the ICU. The present study was designed to assess the prevalence of anxiety and depression in family members of patients admitted in a general medicine department, and to identify associated factors with those symptoms. METHODS: Patients' and relatives' socio-demographic data and information pertaining to the patients' health characteristics were collected. Family members completed the Arabic version of Hospital Anxiety and Depression Scale (HADS). Associations between anxiety or depression and covariates of interest were investigated using generalized estimating equations, for univariate and multivariate logistic regression analysis. RESULTS: The prevalence of anxiety (55.6%) and depression (41.1%) in family members remains high. The multivariate model identified three groups of factors associated with these symptoms: (i) Patient related: a short length of hospital stay is associated with depression (OR 1.04, 95% CI 1.01-1.08; P = 0.02); (ii) Family related: rural residence is associated with depression (OR 2.56, 95% CI 1.01-6.74; P = 0.04), and female gender is associated with anxiety and depression (OR 2.60, 95% CI 1.41-4.81; P = 0.002), (OR 3.04, 95% CI 1.62-5.70; P = 0.01), respectively; and (iii) Caregiver related: short length of visit (OR 1.08, 95% CI 1.03-1.13; P = 0.002) is associated with anxiety, admission to a share room (OR 2.56, 95% CI 1.25-5.23; P = 0.01) is associated with depression and a need for more information is associated with anxiety and depression (OR 1.78, 95% CI 1.02-3.10; P = 0.04),(OR 1.77, 95% CI 1.01-3.11; P = 0.04), respectively. CONCLUSION: The prevalence of symptoms of anxiety and depression in family members remains high at the end of acute health care. It is hoped that improving the provision of information will decrease the risk of psychological distress.

[Epidemiology of maternal-fetal group B streptococcal infections]. / Épidémiologie des infections materno-fœtales à streptocoque du groupe B.

GOAL: The aim of this study was to determine the incidence, risk factors, and outcome of maternal-fetal infection due to group B streptococcus. PATIENTS AND METHODS: We identified all cases of maternal-fetal group B streptococcus infection between January 2003 and December 2007, from neonatal unit reports at the Charles Nicolle Hospital. RESULTS: Ninety cases were identified out of 17,922 live births, incidence 5 ‰ of which 2.3 ‰ of bacteremia. Twenty percent of all newborns were premature and 22.2% had a low birth weight. Peripartum maternal fever was recorded in 52.2% of cases and membrane rupture more than 12 hours before delivery occurred in 74.4%. Among the newborns, 45.6% were symptomatic at birth. Forty percent of group B streptococci were resistant to erythromycin and 3.3% with intermediate resistance to ampicillin. The global neonatal mortality after group B streptococcus infection was 3.3%. CONCLUSION: Maternal-fetal infection due to group B streptococcus is still frequent and continues to be a major cause of morbidity and mortality.

[Usefulness of serum procalcitonin in the early diagnosis of maternal-fetal bacterial infection. A prospective study]. / Apport de la procalcitonine dans le diagnostic précoce de l'infection materno-fœtale bactérienne. Étude prospective.

UNLABELLED: Early diagnosis avoiding unnecessary treatment of maternal-fetal bacterial infection remains one of the greatest challenges for obstetricians and pediatricians. To meet these objectives, many inflammatory mediators were used, including procalcitonin (PCT). The aim of our study was to determine the usefulness of PCT in early diagnosis and management of neonatal infection. SUBJECTS AND METHODS: Over a period of 8 months, all living newborns with highly suspected maternal-fetal bacterial infection who were to receive antibiotic treatment according to our neonatal unit protocol were included in this prospective study. Serum PCT concentrations were determined at birth and after 12h of life using a specific immunoluminometric assay. Two distinct populations were defined based on clinical, biological, and bacteriological criteria: group 1: infected neonates, and group 2: noninfected neonates. STATISTICAL METHODS: We compared PCT means in different groups and determined the cut-off value correlated with maternal-fetal bacterial infection by analyzing the receiver operating characteristics curve (ROC). RESULTS: A total of 130 neonates were included in the study: 38 (29%) were classified in group 1 with 29 possible infections and 9 defined infections, including 5 cases of septicemia. The average PCT at birth in group 1 was significantly higher than in group 2 (3.52 ± 8.19 ng/ml vs 0.43 ± 0.73 ng/ml; P<0.001). The PCT threshold value at birth found by the ROC curve with the highest sensitivity (71.1%) and highest specificity (62%) was 0.215 ng/ml. The negative predictive value (NPV) was 83.8%, making it possible to avoid unnecessary treatment in the majority of the cases. The PCT threshold value within 12h of birth was 3.78 ng/ml, for a sensitivity of 89.5% and 1 NPV of 94.4%. CONCLUSION: PCT is a valuable biological examination because it can be administered early, it is sensitive, and it has a NPV. These characteristics make PCT a biological argument that can be used in the initial decision on whether to administer antibiotics. Another study will be conducted to establish the cut-off value.

Measurement properties of the short form 36 and health-related quality of life after intensive care in Morocco.

BACKGROUND: Intensive care patients have a health-related quality of life (HRQL) that differs from the normal population. The aim of this study was to evaluate the measurement properties of the Arabic version of the short form (SF)-36 and study the HRQL determinants in adult patients 3 months after discharge from an intensive care unit (ICU). METHODS: A prospective cohort study after ICU discharge. At 3-month follow up, the SF-36 was administered in consultation or by telephone. Multitrait scaling analysis was used to confirm the hypothesized scale structure of the SF-36. Reliability was tested using (i) measuring internal consistency; and (ii) the test-retest reliability assessed using an intraclass correlation coefficient. Construct validity was tested by known-groups comparison using one-way analysis of variance (ANOVA) and analysis of covariance (ANCOVA). RESULTS: A total of 145 survivors answered the SF-36. Item internal convergency was higher than 0.40 (0.77-0.99; 100% scaling success) and item discriminant validity was perfect (100% scaling success) except for physical functioning (81% scaling success). Cronbach's alpha exceeded 0.70 in all eight scales (0.84-0.99). Test-retest reliability conducted in 73 patients was above 0.80. Acceptability to patients appeared reasonable although considerable interview time was required to administer the SF-36. Construct validity was confirmed by lower scores being reported by women, older age and a high level of comorbidities groups. When adjusted for background data, ICU variables were not associated with the SF-36 scores. CONCLUSIONS: The Arabic version of the SF-36 appears to be a robust tool in ICU. Background variables are the only significant determinants of HRQL 3 months after medical ICU discharge.

[Mortality and prognostic factors of the cirrhotic patients with hepatic encephalopathy admitted to medical intensive care unit]. / Mortalité et facteurs pronostiques des patients cirrhotiques en encéphalopathie hépatique admis en réanimation.

OBJECTIVE: To assess mortality and to identify variables that could predict it in cirrhotic patients hospitalized to the medical intensive care unit (MICU) for hepatic encephalopathy (HE). STUDY DESIGN: Retrospective cohort study. PATIENTS AND METHODS: From January 1995 to December 2004, the cirrhotic patients admitted consecutively in MICU were screened and those with altered level of consciousness were included. The MICU mortality rate was assessed. Nearly 80 variables were analyzed and compared between survivors and non-survivors. STATISTICAL ANALYSIS: t test, chi(2) or Fisher exact tests, Kaplan-Meier and log rank, Cox regression analysis. RESULTS: A total of 180 patients (42 women-138 men, mean age: 59+/-10 years) were admitted (incidence: 2.6%). The SAPS II was 30.1+/-11, Acute Physiology Age and Chronic Health Evaluation II (APACHE II): 16.5+/-5.3, Child-Pugh score: 9.1+/-1.9 and GCS: 11+/-2.8. The causes of liver cirrhosis was identified in 41.2% of cases (viral: 35.6%, alcohol: 5.6%). Nearly 18% of patients had an antecedent of HE. The causes of HE were: infection (65.6%), upper gastrointestinal bleeding (32.2%), drugs (5%) and metabolic cause (5%). MICU mortality rate was 33.3% and seemed higher in gastrointestinal bleeding. Eighteen variables were significantly associated with poor prognosis in univariate analysis. Only three variables remained significant in multivariate analysis: systolic blood pressure<90 mmHg (RR=4; IC 95%=2-8.1), total WBC>12000 n/mm(3) (RR=3.1; IC 95%=1.8-5.3) and use of mechanical ventilation (RR=3.1; IC 95%=1.7-5.6). CONCLUSION: The MICU mortality of cirrhotic patients with HE was high and significantly associated with haemodynamic instability, hyperleucocytosis and mechanical ventilation.