Sepsis and septic shock in patients with malignancies : a Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique study

Objectives: Cancer affects up to 20% of critically ill patients, and sepsis is one of the leading reasons for ICU admission in this setting. Early signals suggested that survival might be increasing in this population. However, confirmation studies have been lacking. The goal of this study was to assess trends in survival rates over time in cancer patients admitted to the ICU for sepsis or septic shock over the last 2 decades. Data Source: Seven European ICUs. Study Selection: A hierarchical model taking into account the year of admission and the source dataset as random variables was used to identify risk factors for day 30 mortality. Data Extraction: Data from cancer patients admitted to ICUs for sepsis or septic shock were extracted from the Groupe de Recherche Respiratoire en Reanimation Onco-Hematologique database (1994-2015). Data Synthesis: Overall, 2,062 patients (62% men, median [interquartile range] age 59 yr [48-67 yr]) were included in the study. Underlying malignancies were solid tumors (n = 362; 17.6%) or hematologic malignancies (n = 1,700; 82.4%), including acute leukemia (n = 591; 28.7%), non-Hodgkin lymphoma (n = 461; 22.3%), and myeloma (n = 244; 11.8%). Two-hundred fifty patients (12%) underwent allogeneic hematopoietic stem cell transplantation and 640 (31.0%) were neutropenic at ICU admission. Day 30 mortality was 39.9% (823 deaths). The year of ICU admission was associated with significant decrease in day 30 mortality over time (odds ratio, 0.96; 95% CI, 0.93-0.98; p = 0.001). Mechanical ventilation (odds ratio, 3.25; 95% CI, 2.52-4.19; p < 0.01) and vasopressors use (odds ratio, 1.42; 95% CI, 1.10-1.83; p < 0.01) were independently associated with day 30 mortality, whereas underlying malignancy, allogeneic hematopoietic stem cell transplantation, and neutropenia were not. Conclusions: Survival in critically ill oncology and hematology patients with sepsis improved significantly over time. As outcomes improve, clinicians should consider updating admission policies and goals of care in this population

Influence of neutropenia on mortality of critically ill cancer patients : results of a meta-analysis on individual data

Background: The study objective was to assess the influence of neutropenia on outcome of critically ill cancer patients by meta-analysis of individual data. Secondary objectives were to assess the influence of neutropenia on outcome of critically ill patients in prespecified subgroups (according to underlying tumor, period of admission, need for mechanical ventilation and use of granulocyte colony stimulating factor (G-CSF)). Methods: Data sources were PubMed and the Cochrane database. Study selection included articles focusing on critically ill cancer patients published in English and studies in humans from May 2005 to May 2015. For study selection, the study eligibility was assessed by two investigators. Individual data from selected studies were obtained from corresponding authors. Results: Overall, 114 studies were identified and authors of 30 studies (26.3% of selected studies) agreed to participate in this study. Of the 7515 included patients, three were excluded due to a missing major variable (neutropenia or mortality) leading to analysis of 7512 patients, including 1702 neutropenic patients (22.6%). After adjustment for confounders, and taking study effect into account, neutropenia was independently associated with mortality (OR 1.41; 95% CI 1.23-1.62; P = 0.03). When analyzed separately, neither admission period, underlying malignancy nor need for mechanical ventilation modified the prognostic influence of neutropenia on outcome. However, among patients for whom data on G-CSF administration were available (n = 1949; 25.9%), neutropenia was no longer associated with outcome in patients receiving G-CSF (OR 1.03; 95% CI 0.70-1.51; P = 0.90). Conclusion: Among 7512 critically ill cancer patients included in this systematic review, neutropenia was independently associated with poor outcome despite a meaningful survival. Neutropenia was no longer significantly associated with outcome in patients treated by G-CSF, which may suggest a beneficial effect of G-CSF in neutropenic critically ill cancer patients

The FOXO1 Transcription Factor Instructs the Germinal Center Dark Zone Program

SummaryThe pathways regulating formation of the germinal center (GC) dark zone (DZ) and light zone (LZ) are unknown. In this study we show that FOXO1 transcription factor expression was restricted to the GC DZ and was required for DZ formation, since its absence in mice led to the loss of DZ gene programs and the formation of LZ-only GCs. FOXO1-negative GC B cells displayed normal somatic hypermutation but defective affinity maturation and class switch recombination. The function of FOXO1 in sustaining the DZ program involved the trans-activation of the chemokine receptor CXCR4, and cooperation with the BCL6 transcription factor in the trans-repression of genes involved in immune activation, DNA repair, and plasma cell differentiation. These results also have implications for the role of FOXO1 in lymphomagenesis because they suggest that constitutive FOXO1 activity might be required for the oncogenic activity of deregulated BCL6 expression

Renal Function in Critically-Il and Hypoxemic Patients

Pas de résumé françaisPas de résumé anglai

Outils d'évaluation de la réponse rénale aux agressions chez le patient de réanimation

Pas de résumé françaisPas de résumé anglaisPARIS-EST-Université (770839901) / SudocPARIS12-Bib. électronique (940280011) / SudocSudocFranceF

Syndrome de lyse tumorale aiguë chez les patients d'hématologie admis en réanimation

Le syndrome de lyse tumorale aiguë (SLT) est la conséquence d une destruction massive de cellules tumorales. Il peut se manifester uniquement par des anomalies biologiques (SLT biologique) mais aussi par des défaillances viscérales (SLT clinique). Aucune étude ne s est à ce jour intéressée au pronostic des patients admis en réanimation pour un syndrome de lyse tumorale.Il s'agit d'une étude observationnelle incluant l ensemble des patients admis en réanimation avec un SLT. 63 patients âgés de 50 ans [32-64] ont été inclus dans cette étude. Trente-cinq avaient un SLT clinique, dont la manifestation viscérale était systématiquement une insuffisance rénale. Une hémopathie était en cause chez 58 patients. A l admission en réanimation, les principales anomalies biologiques étaient des LDH à 3110 IU/L (1701-6756), un produit phospho-calcique à 3.58 (2.61-4.50) et un acide urique à 451 mol/L (179-706). La mortalité hospitalière et à 6 mois était significativement plus basse chez les patients avec un SLT biologique (7% et 21%) que chez les patients avec SLT clinique (51% et 66%). La mortalité des patients avec SLT biologique restait significativement plus basse que celle des patients avec SLT clinique après ajustement pour la sévérité, et ce que ce soit pour la mortalité hospitalière (OR 0.09; 95% IC95% 0.02-0.50; P=0.005) ou à 6 mois (OR 0.23; 95% IC95% 0.07-0.75; P=0.006). Cette étude aura permis d évaluer les caractéristiques cliniques et démographiques de ces patients. Elle aura également mis en évidence le pronostic favorable à long terme des patients hospitalisés en réanimation avec un syndrome de lyse tumorale biologique.PARIS6-Bibl.Pitié-Salpêtrie (751132101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

L'industrie pharmaceutique étrangère en Chine (espoir ou désillusion)

CHATENAY M.-PARIS 11-BU Pharma. (920192101) / SudocSudocFranceF

Le syndrome de détresse respiratoire aiguë en sortie d'aplasie

PARIS7-Xavier Bichat (751182101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Modeling of ray paths of head waves on irregular interfaces in TOFD inspection for NDE

International audienceThe TOFD (Time of Flight Diffraction) technique is a classical ultrasonic inspection method used in ultrasonic non-destructive evaluation (NDE). This inspection technique is based on an arrangement of two probes of opposite beam directions and allows a precise positioning and a quantitative evaluation of the size of cracks contained in the inspected material thanks to their edges diffraction echoes. Among the typical phenomena arising for such an arrangement, head waves, which propagate along the specimen surface and are chronologically the first waves reaching the receiver, are notably observed. Head wave propagation on planar surfaces in TOFD configurations is well known. However, realistic inspection configurations often involve components with irregular surfaces, like steel excavated specimens. Surface irregularity is responsible for numerous effects on the scattering of bulk waves, causing the melting of surface and bulk mechanisms in the head wave propagation. In order to extend the classical ray approach on these complex cases, a generic algorithm of ray tracing between interface points (GIRT) has been designed. With respect to time of flight minimization (i.e. the Generalized Fermat's Principle), ray paths can be computed by GIRT for different natures of waves scattered by the complex surfaces or by flaws. The head wave fronts computed by GIRT are notably in good agreement with FEM simulated results. This algorithm, based on pure kinematic analysis of waves propagation, represents a first step in the future development of a complete ray theory for head waves simulation on irregular interfaces