Impact of early enteral versus parenteral nutrition on mortality in patients requiring mechanical ventilation and catecholamines: study protocol for a randomized controlled trial (NUTRIREA-2)

BACKGROUND: Nutritional support is crucial to the management of patients receiving invasive mechanical ventilation (IMV) and the most commonly prescribed treatment in intensive care units (ICUs). International guidelines consistently indicate that enteral nutrition (EN) should be preferred over parenteral nutrition (PN) whenever possible and started as early as possible. However, no adequately designed study has evaluated whether a specific nutritional modality is associated with decreased mortality. The primary goal of this trial is to assess the hypothesis that early first-line EN, as compared to early first-line PN, decreases day 28 all-cause mortality in patients receiving IMV and vasoactive drugs for shock. METHODS/DESIGN: The NUTRIREA-2 study is a multicenter, open-label, parallel-group, randomized controlled trial comparing early PN versus early EN in critically ill patients requiring IMV for an expected duration of at least 48 hours, combined with vasoactive drugs, for shock. Patients will be allocated at random to first-line PN for at least 72 hours or to first-line EN. In both groups, nutritional support will be started within 24 hours after IMV initiation. Calorie targets will be 20 to 25 kcal/kg/day during the first week, then 25 to 30 kcal/kg/day thereafter. Patients receiving PN may be switched to EN after at least 72 hours in the event of shock resolution (no vasoactive drugs for 24 consecutive hours and arterial lactic acid level below 2 mmol/L). On day 7, all patients receiving PN and having no contraindications to EN will be switched to EN. In both groups, supplemental PN may be added to EN after day 7 in patients with persistent intolerance to EN and inadequate calorie intake. We plan to recruit 2,854 patients at 44 participating ICUs. DISCUSSION: The NUTRIREA-2 study is the first large randomized controlled trial designed to assess the hypothesis that early EN improves survival compared to early PN in ICU patients. Enrollment started on 22 March 2013 and is expected to end in November 2015. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01802099 (registered 27 February 2013)

Adipokines in human vascular pathologies : coronary-carotid atherosclerosis and abdominal aortic aneurysm

L’obésité est une cause majeure de morbi-mortalité dans le monde en raison notamment du risque accru de développement de pathologies cardiovasculaires athéroscléreuses. Elle est en particulier associée à une accumulation de tissu adipeux blanc secrétant une quantité inappropriée de cytokines possédant des effets pléiotropiques sur l’inflammation et le métabolisme : les adipokines dont la leptine, la résistine et l’adiponectine. L’anévrysme de l’aorte abdominale (AAA) est une dilatation localisée et permanente de plus de 50% du diamètre de l’aorte abdominale. Il a longtemps été considéré comme une complication de l’athérosclérose. Cependant, cette théorie a été mise à l’épreuve récemment. Très peu d’études se sont intéressées à la prévalence et aux facteurs de risque d’AAA chez les patients coronariens. Dans une première partie, nous avons montré dans une population de 217 patients opérés d’un pontage aorto-coronarien pour une athérosclérose coronarienne sévère que la prévalence de l’AAA atteint 24% si l’on considère les hommes avec un tabagisme actif ou ancien et présentant de manière concomitante une atteinte athéroscléreuse d’autres lits vasculaires (sténose carotidienne ou artérite oblitérante des membres inférieurs), pour une prévalence de seulement 4,4% en l’absence de ces facteurs de risque. Dans la population générale, le dépistage d’un AAA est recommandé seulement chez les hommes âgés de 65 à 75 ans ayant des antécédents de tabagisme. Aucune donnée n’existe sur le dépistage des AAA chez les patients coronariens. Dans la seconde partie de ce travail, nous avons donc réalisé une revue de la littérature sur les facteurs de risque prédictifs d’AAA chez les patients coronariens. Malgré le nombre réduit d’études, la prévalence de l’AAA est plus élevée dans une population atteinte d’athérosclérose coronarienne que dans la population générale. Certains facteurs de risques traditionnels de l’athérosclérose (tabagisme, âge et atteinte athéroscléreuse d’autres lits vasculaires) maintiennent chez ces patients une association significative avec l’AAA. Un AAA n’est probablement donc pas une simple complication de l’athérosclérose et l’intérêt du dépistage de l’AAA dans cette population spécifique de patients mérite d’être approfondi. Une inflammation transmurale chronique caractérise à la fois le développement de l’athérosclérose et de l’AAA. Nous avons évalué l’association des taux plasmatiques des 3 principales adipokines (résistine, leptine et adiponectine) avec la prévalence de l’AAA dans notre population de patients coronariens sévères. Nous avons montré que seul le taux plasmatique de résistine était indépendamment associé à l’AAA et corrélé au diamètre infra-rénal de l’aorte. Cette corrélation disparaissait dans le groupe des AAA. Ainsi la résistine pourrait être associée à la pathogenèse de l’AAA, indépendamment de son implication dans le processus inflammatoire à l’origine de l’athérosclérose. Enfin, la quatrième partie de notre travail a porté sur le rôle de la leptine dans le développement de lésions athéroscléreuses de l’artère carotidienne. Dans un protocole clinico-biologique incluant des patients atteints d’une athérosclérose carotidienne symptomatique ou pas, nécessitant une endartérectomie (n=146), nous avons montré pour la première fois que les taux plasmatiques et intra-plaques de leptine sont significativement plus bas chez les patients asymptomatiques que chez les patients symptomatiques, ce qui a été confirmé par analyse multivariée. Les taux de leptine plasmatiques et intra plaques sont positivement corrélés à un phénotype stable de la plaque (ratio collagène/macrophages élevé). Nous avons également montré qu’in vitro, la leptine induit initialement une réponse de migration sur les CMLV (0-20 ng/mL), puis de prolifération (20 à 75 ng/mL). [...]Obesity is associated with a higher risk of atherosclerotic cardiovascular pathologies and accordingly entails a great deal of morbidity and mortality. Central to obesity is the accumulation of large amounts of white adipose tissue, which inappropriately secretes bioactive molecules involved in a state of local and systemic low grade inflammation as well as metabolic anomalies. These molecules are the adipokines including leptin, resistin and adiponectin. An abdominal aortic aneurysm (AAA) is a localized and permanent aortic dilation, exceeding 50% of the adjacent normal aortic wall diameter. AAA has long been considered an atherosclerotic complication, a theory which has recently been challenged. Only a few studies have evaluated the prevalence and risk factors of AAA in coronary artery disease (CAD) patients. In the first part of our work, we dealt with 217 patients undergoing coronary artery bypass grafting for severe CAD. In men aged less than 75 years with a smoking history, AAA prevalence reached 24% if they had concomitant peripheral artery disease or carotid artery stenosis, vs 4.4% in the absence of either condition. AAA screening is only recommended in men, aged 65 to 75 years, with a history of smoking. Na data are available on the need for AAA screening among CAD patients. The second part of our work is a review on the prevalence and risk factors of AAA in CAD patients. Despite a limited number of studies, AAA seems to be more prevalent among CAD patients compared to the global population. Only some traditional atherosclerosis risk factors remain significantly associated with AAA (smoking, age, atherosclerosis of other vascular beds). Accordingly, AAA may not be pressed into a simple scheme as just an atherosclerotic complication. The benefit of AAA screening in this specific sub-population needs to be further assessed. Both AAA and atherosclerosis share chronic arterial wall inflammation. Hence, in the 3rd part of the current work, we measured circulating levels of the 3 main adipokines (leptin, resistin and adiponectin) and assessed their relationship with the presence of AAA among our precited severe CAD male patients. Only serum resistin levels were independently associated with AAA, and correlated with infra renal aortic diameter. This correlation disappeared in the AAA range. Eventually, resistin could be associated with AAA pathogenesis, independently of its implication in atherosclerosis – related inflammation. The fourth and final part of our work has acknowledged the role of leptin in the development of atherosclerotic carotid artery stenosis. We included 146 patients scheduled for carotid endarterectomy for asymptomatic versus symptomatic carotid artery stenosis. We reported, for the first time, that serum and intra–plaque leptin levels were significantly lower in symptomatic patients compared to asymptomatic patients. This result was confirmed by multivariate analysis. Circulating and intra plaque levels were positively correlated to a stable plaque phenotype (high collagen/macrophage ratio). In vitro, leptin induced an initial migratory response on vascular smooth muscle cells (VSMC) at the concentration range of 0 to 20 ng/mL, followed by a proliferative response (20 to 75 ng/mL). At higher concentrations (100 ng/mL), leptin brought about VSMC apoptosis. Leptin could thus play an active role in carotid plaque stabilization, via its effects on VSMC. Several conclusions can be drawn. AAA is not a mere atherosclerotic complication. On one side, resistin could actively influence the development and progression of AAA. On the opposite side, leptin could promote atherosclerotic plaque stabilization, via its effects on VSMC migration and proliferation

Coronavirus Disease 2019-Associated Mucormycosis in France: A Rare but Deadly Complication

International audienceWe studied COVID-19 associated mucormycosis based on 17 cases reported nationwide and assessed the differences with India. They differed by frequencies of diabetes mellitus (47% in France versus up to 95% in India), hematological malignancies (35% versus 1%), anatomical sites (12% versus >80% rhino-orbito-cerebral) and prognosis (88% mortality versus <50%)

Coronavirus Disease 2019-Associated Mucormycosis in France: A Rare but Deadly Complication

International audienceWe studied COVID-19 associated mucormycosis based on 17 cases reported nationwide and assessed the differences with India. They differed by frequencies of diabetes mellitus (47% in France versus up to 95% in India), hematological malignancies (35% versus 1%), anatomical sites (12% versus >80% rhino-orbito-cerebral) and prognosis (88% mortality versus <50%)

Coronavirus Disease 2019-Associated Mucormycosis in France: A Rare but Deadly Complication

International audienceWe studied COVID-19 associated mucormycosis based on 17 cases reported nationwide and assessed the differences with India. They differed by frequencies of diabetes mellitus (47% in France versus up to 95% in India), hematological malignancies (35% versus 1%), anatomical sites (12% versus >80% rhino-orbito-cerebral) and prognosis (88% mortality versus <50%)

Coronavirus Disease 2019-Associated Mucormycosis in France: A Rare but Deadly Complication

International audienceAbstract We studied COVID-19 associated mucormycosis based on 17 cases reported nationwide and assessed the differences with India. They differed by frequencies of diabetes mellitus (47% in France versus up to 95% in India), hematological malignancies (35% versus 1%), anatomical sites (12% versus &gt;80% rhino-orbito-cerebral) and prognosis (88% mortality versus &lt;50%)

Assessment of Magnetic Resonance Imaging Changes and Functional Outcomes Among Adults With Severe Herpes Simplex Encephalitis

International audienceImportance: Current guidelines recommend brain magnetic resonance imaging (MRI) for clinical management of patients with severe herpes simplex encephalitis (HSE). However, the prognostic value of brain imaging has not been demonstrated in this setting.Objective: To investigate the association between early brain MRI data and functional outcomes of patients with HSE at 90 days after intensive care unit (ICU) admission.Design, setting, and participants: This multicenter cohort study was conducted in 34 ICUs in France from 2007 to 2019 and recruited all patients who received a clinical diagnosis of encephalitis and exhibited cerebrospinal fluid positivity for herpes simplex virus DNA in the polymerase chain reaction analysis. Data analysis was performed from January to April 2020.Exposures: All patients underwent a standard brain MRI during the first 30 days after ICU admission.Main outcomes and measures: MRI acquisitions were analyzed by radiologists blinded to patients' outcomes, using a predefined score. Multivariable logistic regression and supervised hierarchical classifiers methods were used to identify factors associated with poor outcome at 90 days, defined by a score of 3 to 6 (indicating moderate-to-severe disability or death) on the Modified Rankin Scale.Results: Overall, 138 patients (median [interquartile range {IQR}] age, 62.6 [54.0-72.0] years; 75 men [54.3%]) with an admission median (IQR) Glasgow Coma Scale score of 9 (6-12) were studied. The median (IQR) delay between ICU admission and MRI was 1 (1-7) days. At 90 days, 95 patients (68.8%) had a poor outcome, including 16 deaths (11.6%). The presence of fluid-attenuated inversion recovery MRI signal abnormalities in more than 3 brain lobes (odds ratio [OR], 25.71; 95% CI, 1.21-554.42), age older than 60 years (OR, 7.62; 95% CI, 2.02-28.91), and the presence of diffusion-weighted MRI signal abnormalities in the left thalamus (OR, 6.90; 95% CI, 1.12-43.00) were independently associated with poor outcome. Machine learning models identified bilateral diffusion abnormalities as an additional factor associated with poor outcome (34 of 39 patients [87.2%] with bilateral abnormalities had poor outcomes) and confirmed the functional burden of left thalamic lesions, particularly in older patients (all 11 patients aged >60 years had left thalamic lesions).Conclusions and relevance: These findings suggest that in adult patients with HSE requiring ICU admission, extensive MRI changes in the brain are independently associated with poor functional outcome at 90 days. Thalamic diffusion signal changes were frequently observed and were associated with poor prognosis, mainly in older patients

High-Dose Dexamethasone and Oxygen Support Strategies in Intensive Care Unit Patients With Severe COVID-19 Acute Hypoxemic Respiratory Failure

International audienc