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Biomedical subjects

E Azoulay

Publications and source records attributed to E Azoulay.

At least 19 recordsLinked to original sources
PubMed2006

Prognostic value of inhibitory anti-ADAMTS13 antibodies in adult-acquired thrombotic thrombocytopenic purpura.

In order to assess the prognostic value of inhibitory anti-ADAMTS13 antibodies in thrombotic thrombocytopenic purpura (TTP), we performed a multicentre prospective study of 33 adult patients with idiopathic acquired TTP. Patients were treated with high-dose plasma infusion and therapeutic plasma exchange. Patients without (group 1, n = 12) and with (group 2, n = 21) detectable inhibitory anti-ADAMTS13 antibodies were compared for clinical presentation, treatment and outcome. Both groups were comparable for clinical presentation. All patients in group 1 achieved a sustained complete remission within a median of 7 d [95% confidence interval (CI), 4-18], which required a median plasma volume of 235 ml/kg (range, 131-1251). In group 2, 17 patients achieved a durable complete remission within a median of 23 d (95% CI, 11-32) (P = 0.001). Median plasma volume was 718 ml/kg (range, 219-3107) (P = 0.02). In group 2, there was a trend for more episodes of flare-up than in group 1 (13 vs. 3, respectively, P = 0.07). Four patients, all from group 2, died (P = not significant). The relapse rate was comparable between both groups. We suggest that TTP with detectable inhibitory anti-ADAMTS13 antibodies displays a worse prognosis, relative to a delayed platelet count recovery, a higher plasma volume requirement to achieve complete remission, and a trend for more frequent episodes of flare-up.

ADAM Proteins↗
PubMed2006

[Limiting life sustaining therapies].

INTRODUCTION: Intensivists are increasingly implementing end-of-life decisions in patients who remain dependent on life sustaining therapies without hope for recovery. STATE OF THE ART: Descriptive studies have provided epidemiological data on ICU end-of-life care, identifying areas for improvement. Qualitative studies have highlighted the complexity of the decision making process. In addition to considering the legal and ethical issues involved, this review describes cultural, religious and individual variations observed in ICU end-of-life care. It is important for intensivists to respect patients' preferences and values, but also, in some family members, to avoid increasing the burden and the guilt of sharing the decision. CONCLUSION: Intensivists should improve their ability to meet the needs of dying patients and their family members. Each situation, patient, family and caregiver is unique, and therefore needs a specific approach. Introducing palliative care and multidisciplinary teams into the ICU might provide an additional opportunity for patients and families to be informed and listened to.

Communication↗
PubMed2005

[Pulmonary legionellosis at the earliest stage of hairy cell leukemia].

Legionella pneumonia is frequently reported in immunocompromised patients. The most important predisposing factor is a quantitative and qualitative defect of the monocytic-macrophagic system. We report a case of Legionella pneumophila in a 43-year-old man revealing hairy cell leukemia. The patient presented with community-acquired pneumonia resistant to common antibiotics. Serology provided the diagnosis and the patient improved with adequate treatment. Early diagnosis and appropriate treatment may reduce the mortality of this serious complication.

Adult↗
PubMed2005

[Diagnosis and management of pleural effusions in critically iII patients].

INTRODUCTION: Pleural effusions are common in ICU patients. Causes include massive fluid resuscitation in shock, pneumonia--either community acquired or nosocomial, cardiac insufficiency, hypoalbuminemia and hepatic impairment. Pleural effusions frequently complicate cardiac and abdominal surgery and haemothorax may complicate trauma. STATE OF THE ART: The incidence of pleural effusions in the intensive care unit (ICU) varies depending on the screening method used, from about 8% for physical examination to more than 60% for routine ultrasonography. In the absence of clinical parameters to exclude infection pleurocentesis remains an essential aspect of management and is not contraindicated mechanical ventilation. This review of the diagnosis and management of pleural effusions in ICU patients reports the most recent data from the literature. Pleurocentesis can be performed safely in the ICU, even in mechanically ventilated patients. The absence of reliable clinical or laboratory test criteria for determining the cause of pleural effusions and the potentially devastating consequences of failing to diagnose and treat pleural infection are strong reasons to perform pleurocentesis in patients with clinically detectable pleural effusions and no contraindication to the procedure. PERSPECTIVES: Although the data reviewed indicate that the diagnosis and treatment of pleural effusions should follow the same rules in the ICU as they do elsewhere, several incompletely resolved issues deserve further investigation. These are summarised in an agenda for future research.

Critical Illness↗
PubMed2005

Respiratory status deterioration during G-CSF-induced neutropenia recovery.

Exacerbation of prior pulmonary involvement may occur during neutropenia recovery. Granulocyte colony-stimulating factor (G-CSF)-related pulmonary toxicity has been documented in cancer patients, and experimental models suggest a role for G-CSF in acute lung injury during neutropenia recovery. We reviewed 20 cases of noncardiac acute respiratory failure during G-CSF-induced neutropenia recovery. Half the patients had received hematopoietic stem cell transplants. All patients experienced pulmonary infiltrates during neutropenia followed by respiratory status deterioration coinciding with neutropenia recovery. Neutropenia duration was 10 (4-22) days, and time between respiratory symptoms and the first day with more than 1000 leukocytes/mm3 was 1 (-0.5 to 2) day. Of the 20 patients, 16 received invasive or noninvasive mechanical ventilation, including 14 patients with acute respiratory distress syndrome (ARDS). Five patients died, with refractory ARDS. In patients with pulmonary infiltrates during neutropenia, G-CSF-induced neutropenia recovery carries a risk of respiratory status deterioration with acute lung injury or ARDS. Clinicians must maintain a high index of suspicion for this diagnosis, which requires eliminating another cause of acute respiratory failure, G-CSF discontinuation and ICU transfer for early supportive management including diagnostic confirmation and noninvasive mechanical ventilation.

Adult↗
PubMed2004

Sedation, sucralfate, and antibiotic use are potential means for protection against early-onset ventilator-associated pneumonia.

To examine risk factors for early-onset ventilator-associated pneumonia (EOP) in patients requiring mechanical ventilation (MV), we performed a prospective cohort study that included 747 patients. Pneumonia was defined as a positive result for a protected quantitative distal sample. EOP was defined as pneumonia that occurred from day 3 to day 7 of MV. Eighty patients (10.7%) experienced EOP. Independent predictors of EOP were male sex (odds ratio [OR], 2.06; 95% confidence interval [CI], 1.18-3.63), actual Glasgow Coma Scale value of 6-13 (OR, 1.95; 95% CI, 1.2-3.18), high Logistic Organ Dysfunction score at day 2 (OR, 1.12 per point; 95% CI, 1.02-1.23), unplanned extubation (OR, 3.19; 95% CI, 1.28-7.92), and sucralfate use (OR, 1.81; 95% CI, 1.01-3.26). Protection occurred with use of aminoglycosides (OR, 0.36; 95% CI, 0.17-0.76), beta -lactams and/or beta -lactamase inhibitors (OR, 0.47; 95% CI, 0.28-0.83), or third-generation cephalosporins (OR, 0.33; 95% CI, 0.16-0.74). Sucralfate use and unplanned extubation are independent risk factors for EOP. Use of aminoglycosides, beta-lactams/ beta-lactamase inhibitors, or third-generation cephalosporins protects against EOP.

Aged↗
PubMed2003

[Metformin-associated lactic acidosis precipitated by acute renal failure].

In type II diabetes treated with metformin, lactic acidosis is a rare but severe complication. Commonly patients with lactic acidosis show signs of shock, tissue hypoxia, acute hepatic or renal failure and the link between metformin therapy and lactic acidosis may be coincidental, associated or causal. Excessive plasma metformin concentrations show that lactic acidosis is due to a toxicological mechanism. The case of a 65-year-old woman with type II diabetes, in whom severe type B2 lactic acidosis secondary to metformin was precipitated by acute renal failure, is presented. The association of diuretics with non-steroidal anti-inflammatory drugs and colchicine was responsible for a volume depletion and an acute renal failure. Initial serum creatinine was 643 micromol x l(-1) and arterial blood gas analysis revealed a pH of 7.01. Aggressive volume expansion and correction of the acidosis with intravenous bicarbonate therapy failed. At the intensive care unit, calculated anion gap was 35 mmol x l(-1) (normal range 10-18) and lactate concentration was 12.4 mmol x l(-1), liver profile was normal. Prolonged haemodialysis using bicarbonate dialysate resulted in a favourable outcome. Toxicology confirmed retrospectively the presence of a plasma concentration of metformine of 20 mg x l(-1) (normal <2). One month after this episode she has made a recovery of tubular necrosis, although no longer prescribed metformin. Metformin should be temporally stopped when acute renal failure occurs or is anticipated; patient with acute renal failure and high calculated anion gap should benefit from lactate measurements. Early bicarbonate haemodialysis is an adequate treatment of lactic acidosis caused by accumulation of metformin associated with acute renal failure

Acidosis, Lactic↗
PubMed2003

Inflammatory response to infectious pulmonary injury.

This review describing the inflammatory response to infectious pulmonary injury is focused on the innate immunity of the distal lung to bacterial pneumonia. The fact that the inflammatory response varies to some extent with the bacterial strain responsible for the infection is emphasised. The key cellular components present in the distal lung are described. The major role of alveolar macrophage is described, inasmuch as it responds to the usual daily challenges of bacteria entering the terminal airways and is capable of initiating an inflammatory reaction if the microbial challenge is either too large or too virulent. Under these conditions, the alveolar macrophages initiate an inflammatory response that recruits large numbers of neutrophils into the alveolar spaces. The strategy of the innate immune response may not be to recognise every possible antigen, but rather to focus on a few, highly conserved structures present in large groups of microorganisms. These structures are referred to as pathogen-associated molecular patterns and the receptors of the innate immune system that evolved to recognise them are called pattern-recognition receptors. The soluble factors in innate defence, such as cytokines, are described, and a last paragraph discusses whether a specific inflammatory response could characterise nosocomial pneumonia.

Cytokines↗
PubMed2002

Pneumocystis carinii pneumonia in critically ill patients with malignancy: a descriptive study.

There are few data on Pneumocystis carinii pneumonia (PCP) in critically ill human immunodeficiency virus (HIV)-negative patients. Improved knowledge of the presenting symptoms of and prognostic factors for PCP may help to reduce the high mortality rate associated with PCP in such patients. We retrospectively studied 39 consecutive patients with acute PCP-related respiratory failure and malignancy who were treated at 2 intensive care units (ICUs) during a 10-year period. Univariate logistic regression identified the following 8 predictors of mortality at 30 days after patient admission to the ICU (30-day mortality rate, 33%): complete remission of the malignancy (odds ratio [OR], 0.18), receipt of >1 course of antimalignancy chemotherapy (OR, 17.2), involvement of 4 lobes noted on a chest radiograph (OR, 5), >15% neutrophils in bronchoalveolar lavage [BAL] fluid specimens (OR, 6), Organ System Failure score (OR, 7.33), Simplified Acute Physiology Score II (OR, 1.12), and the need for either mechanical ventilation (OR, 63) or vasopressors (OR, 25.9). Studies are needed to determine whether aggressive monitoring and treatment of patients with >15% neutrophils in BAL fluid specimens can improve the outcome of critically ill patients with malignancy and PCP.

Acute Disease↗
PubMed2001

Development of a p53 responsive GFP reporter; identification of live cells with p53 activity.

p53 is among the most intensely studied human proteins because of its vital role as the prototype tumor suppressor. As a result, there are widespread applications for p53 functional analysis in biotechnology as it relates to cancer research. p53 is a potent sequence specific transcription factor, which induces the expression of a number of genes whose products mediate cell cycle arrest and apoptosis. Because the tumor suppressor activity of p53 is dependent on its transcription regulatory function, we have undertaken to develop a p53-responsive green fluorescent protein reporter strategy to enable the identification of live cells containing p53 transcriptional transactivation activity. We demonstrate within the use of GFP fluorescence to monitor both endogenous and plasmid derived p53 biochemical and biological activity. Identifying live cells with p53 activity through GFP fluorescence will have wide application for both in vitro and in vivo studies of the p53 tumor suppressor protein.

Apoptosis↗
PubMed2001

Effectiveness of platelet transfusions after plasma exchange in adult thrombotic thrombocytopenic purpura: a report of two cases.

Plasma infusion (PI) and plasma exchange (PE) are the most efficient treatment of thrombotic thrombocytopenic purpura (TTP), allowing achievement of complete remission in 60 to 90% of cases. Life-threatening bleeding, related to severe thrombocytopenia, is one of the main complications of the disease. Thrombocytopenia may also preclude invasive procedures such as splenectomy, which may be required during the management of TTP. Platelet concentrates transfusions are usually thought to worsen the disease, especially if not associated with the appropriate treatment of this latter, and thus should be avoided. We report hereon 2 patients with TTP who experienced a surgical procedure i.e., a cholecystectomy for a cholecystitis, and a splenectomy for a refractory TTP. In both patients, the surgical procedure was preceded by a 60 mL/kg plasma exchange with solvent/detergent treated plasma as replacement fluid, followed by platelet transfusion, with a corrected count increment of 57.1% (Patient 1) and 69.3% (Patient 2). Using this sequential treatment, the patients did not experience any deterioration of their status. Both patients had a favorable outcome after surgery. However, until such a procedure will be validated on a larger series of patients, it should be restricted to patients presenting with a refractory life-threatening thrombocytopenia and/or requiring surgery or any kind of invasive procedure. Am. J. Hematol. 68:198-201, 2001. Published 2001 Wiley-Liss, Inc.

Adult↗
PubMed2001

Delayed treatment contributes to mortality in ICU patients with severe active pulmonary tuberculosis and acute respiratory failure.

OBJECTIVES: To clarify the patterns of pulmonary tuberculosis (TB) that should result in a high index of suspicion, to increase the chances of early therapy and to identify predictors of 30-day mortality. PATIENTS AND METHODS: Retrospective, 7-year study in two medical intensive care units (ICUs). All patients admitted with pulmonary TB were enrolled. Clinical and laboratory data at admission and events within 48 h of admission were collected. Predictors of 30-day mortality were identified by univariate and multivariate analysis. RESULTS: The study included 99 patients with a median age of 41 years. Immunodeficiency was present in 60 patients, including 38 with AIDS. Fifty-nine patients had pulmonary TB alone, 22 also had extrapulmonary TB and 18 had miliary. All 99 patients were admitted for acute respiratory failure, some also with shock (20), neurologic disorders (18) or acute renal failure (10). Mechanical ventilation was needed in 50 patients; 22 patients met criteria for acute respiratory distress syndrome (ARDS). The 30-day mortality rate was 26.2%. Four factors independently predicted mortality: a time from symptom onset to treatment of more than 1 month (OR, 3.49; CI, 1.20-10.20), the number of organ failures (OR, 3.15; CI, 1.76-5.76), a serum albumin level above 20 g/l (OR, 3.96; CI, 1.04-15.10), and a larger number of lobes involved on chest radiograph (OR, 1.83; CI, 1.12-2.98). CONCLUSION: Delayed clinical suspicion and treatment of active pulmonary TB with respiratory failure may contribute to the persistently high mortality rates in ICU patients with these diseases.

Acute Disease↗
PubMed2001

Accuracy of a composite score using daily SAPS II and LOD scores for predicting hospital mortality in ICU patients hospitalized for more than 72 h.

UNLABELLED: In most databases used to build general severity scores the median duration of intensive care unit (ICU) stay is less than 3 days. Consequently, these scores are not the most appropriate tools for measuring prognosis in studies dealing with ICU patients hospitalized for more than 72 h. PURPOSE: To develop a new prognostic model based on a general severity score (SAPS II), an organ dysfunction score (LOD) and evolution of both scores during the first 3 days of ICU stay. DESIGN: Prospective multicenter study. SETTING: Twenty-eight intensive care units (ICUs) in France. PATIENTS: A training data-set was created with four ICUs during an 18-month period (893 patients). Seventy percent of the patients were medical (628) aged 66 years. The median SAPS II was 38. The ICU and hospital mortality rates were 22.7% and 30%, respectively. Forty-seven percent (420 patients) were transferred from hospital wards. In this population, the calibration (Hosmer-Lemeshow chi-square: 37.4, P = 0.001) and the discrimination [area under the ROC curves: 0.744 (95 % CI: 0.714-0.773)] of the original SAPS II were relatively poor. A validation data set was created with a random panel of 24 French ICUs during March 1999 (312 patients). MEASUREMENTS AND MAIN RESULTS: The LOD and SAPS II scores were calculated during the first (SAPS1, LOD1), second (SAPS2, LOD2), and third (SAPS3, LOD3) calendar days. The LOD and SAPS scores alterations were assigned the value "1" when scores increased with time and "0" otherwise. A multivariable logistic regression model was used to select variables measured during the first three calendar days, and independently associated with death. Selected variables were: SAPS II at admission [OR: 1.04 (95 % CI: 1.027-1.053) per point], LOD [OR: 1.16 (95 % CI: 1.085-1.253) per point], transfer from ward [OR: 1.74 (95 % CI: 1.25-2.42)], as well as SAPS3-SAPS2 alterations [OR: 1.516 (95 % CI: 1.04-2.22)], and LOD3-LOD2 alterations [OR: 2.00 (95 % CI: 1.29-3.11)]. The final model has good calibration and discrimination properties in the training data set [area under the ROC curve: 0.794 (95 % CI: 0.766-0.820), Hosmer-Lemeshow C statistic: 5.56, P = 0.7]. In the validation data set, the model maintained good accuracy [area under the ROC curve: 0.826 (95 % CI: 0.780-0.867), Hosmer-Lemeshow C statistic: 7.14, P = 0.5]. CONCLUSIONS: The new model using SAPS II and LOD and their evolution during the first calendar days has good discrimination and calibration properties. We propose its use for benchmarking and evaluating the over-risk of death associated with ICU-acquired nosocomial infections.

APACHE↗
PubMed2001

Routine exploratory thoracentesis in ICU patients with pleural effusions: results of a French questionnaire study.

PURPOSE: The purpose of this study was to report the opinions of intensivists regarding pleural effusions in patients in the intensive care unit (ICU). MATERIALS AND METHODS: Questionnaires were sent to 1,032 intensivists, who were members of the French Society of Critical Care. RESULTS: Four hundred thirty-one questionnaires (41.7%) were returned. Overall, the respondents' estimated the incidence of pleural effusion in ICU patients to be 22.19 +/- 17%, whereas 37 +/- 27% considered that exploratory thoracentesis was likely to determine the cause of the effusion, and 17.36 +/- 16% considered that its results were likely to result in a change in their therapeutic attitude. Sixty-five (15%) physicians, chiefly pulmonologists, performed exploratory thoracentesis routinely (Group 1). Compared with those who did not perform routine thoracentesis (Group 2), they ascribed a higher proportion of pleural effusions to infection (31.3% vs. 13.5%) and were more likely to consider that exploratory thoracentesis had a diagnostic and therapeutic contribution (51.2% vs. 34% and 23% vs. 16%, respectively). In addition to the respiratory medicine subspecialty, the practice of routine exploratory thoracentesis was significantly related to seniority, to the frequency of the suspicion of an infectious cause in the physician's practice, and to his or her appreciation of the risks associated with exploratory thoracentesis. Physicians from Group 1 were also more likely to describe exploratory thoracentesis as a noninvasive procedure. CONCLUSIONS: The beliefs and attitudes of intensivists regarding pleural effusions and exploratory thoracentesis are divergent. This may be due to the lack of precise guidelines on the topic and prompt the design of further studies to establish precisely the epidemiology and causes of pleural effusions in ICU patients.

Attitude of Health Personnel↗
PubMed2001

Improved survival in cancer patients requiring mechanical ventilatory support: impact of noninvasive mechanical ventilatory support.

OBJECTIVE: When a cancer patient becomes critically ill, mechanical ventilation (MV) is often considered futile. However, recent studies have found that outcomes of critically ill cancer patients have been improving over the years and that classic predictors of high mortality have lost their relevance. DESIGN: We retrospectively determined outcomes and predictors of 30-day mortality in 237 mechanically-ventilated cancer patients admitted to the intensive care unit (ICU). PATIENTS: The 132 (55.7%) patients who were admitted between 1990 and 1995 were compared with 105 (44.3%) patients who were admitted between 1996 and 1998. The malignancy was leukemia/lymphoma in 119 (50.3%) patients, myeloma in 50 (21%), and a solid tumor in 68 (28.7%). Forty-two (17.7%) patients had bone marrow transplantation, and 91 (38.4%) were neutropenic. Median Simplified Acute Physiology Score II (SAPS II) was 58 (range, 40-75). Reasons for MV were acute hypoxemic respiratory failure in 148 (62.5%) patients, coma in 54 (22.8%), and cardiogenic pulmonary edema in 35 (14.7%). Conventional MV was used first in 189 (79.8%) patients, and noninvasive MV (NIMV) was used in 48 (20.2%). Overall mortality rate was 72.5% (172 deaths). RESULTS: Logistic regression identified three variables associated with mortality: ICU admission between 1996 and 1998 (odds ratio [OR], 0.24; 95% confidence interval [CI], 0.12-0.50) and the use of NIMV (OR, 0.34; 95% CI, 0.16-0.73) were protective, and the SAPS II was aggravating (OR, 1.04 per point; 95% CI, 1.02-1.06). To better define the impact of NIMV, we performed a pairwise-matched exposed-unexposed analysis. Forty-eight patients who did and 48 who did not receive NIMV as the first ventilation method were matched for SAPS II, type of malignancy, and period of ICU admission. Crude ICU mortality rates from exposed patients and controls were 43.7% and 70.8%, respectively. NIMV remained protective from mortality after adjustment for matching variables (OR, 0.31; 95% CI, 0.12-0.82). CONCLUSION: Our results confirm that mortality has improved over the past decade in critically ill cancer patients, even those who require MV, and suggest that this may be, in part, because of a protective effect of NIMV.

APACHE↗