Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome associated with COVID-19: An Emulated Target Trial Analysis.

RATIONALE: Whether COVID patients may benefit from extracorporeal membrane oxygenation (ECMO) compared with conventional invasive mechanical ventilation (IMV) remains unknown. OBJECTIVES: To estimate the effect of ECMO on 90-Day mortality vs IMV only Methods: Among 4,244 critically ill adult patients with COVID-19 included in a multicenter cohort study, we emulated a target trial comparing the treatment strategies of initiating ECMO vs. no ECMO within 7 days of IMV in patients with severe acute respiratory distress syndrome (PaO2/FiO2 <80 or PaCO2 ≥60 mmHg). We controlled for confounding using a multivariable Cox model based on predefined variables. MAIN RESULTS: 1,235 patients met the full eligibility criteria for the emulated trial, among whom 164 patients initiated ECMO. The ECMO strategy had a higher survival probability at Day-7 from the onset of eligibility criteria (87% vs 83%, risk difference: 4%, 95% CI 0;9%) which decreased during follow-up (survival at Day-90: 63% vs 65%, risk difference: -2%, 95% CI -10;5%). However, ECMO was associated with higher survival when performed in high-volume ECMO centers or in regions where a specific ECMO network organization was set up to handle high demand, and when initiated within the first 4 days of MV and in profoundly hypoxemic patients. CONCLUSIONS: In an emulated trial based on a nationwide COVID-19 cohort, we found differential survival over time of an ECMO compared with a no-ECMO strategy. However, ECMO was consistently associated with better outcomes when performed in high-volume centers and in regions with ECMO capacities specifically organized to handle high demand. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Neuromyopathie thyrotoxique (revue de littérature, à propos d'un cas)

CAEN-BU Médecine pharmacie (141182102) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Infections à mycobactéries atypiques du sujet séropositif pour le VIH (à propos de 51 observations)

CAEN-BU Médecine pharmacie (141182102) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Patients intubés-ventilés aux urgences (étude sur le devenir et les délais d'admission en réanimation)

POITIERS-BU Médecine pharmacie (861942103) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Isolated Cerebral Alveolar Echinococcosis

International audienceCerebral alveolar echinococcosis (AE) is rare and mostly associated with liver involvement. We report an exceptional case of a 62-year-old man with a hereditary hemorrhagic telangiectasia harboring a primary cerebral AE mimicking neurocysticercosis with >100 cerebral lesions and without liver involvement. Human alveolar echinococcosis (AE) is a rare zoonotic infection caused by the metacestode of the fox tapeworm, Echinococcus multilocularis. Endemic regions of AE are mainly limited to the Northern Hemisphere, especially to western China, Central Europe, Alaska, Russia, and Japan [1]. The main risk factors associated with human AE are rural settings, living near a forest, mountain climate, being a farmer, and being a dog owner. Humans become accidentally infected through the ingestion of eggs shed in the feces of definite hosts (eg, foxes, dogs) [1]. Primary extrahepatic involvement of AE is rare, and cerebral involvement is unusual [1]. We report an exceptional case of primary cerebral AE in which imaging showed multiple small round contrast-enhancing lesions. We will discuss the general diagnostic approach of brain abscesses, including the differential diagnosis of multiple abscesses and the physiopathology of isolated brain involvement in this case of AE. CASE REPORT We report the case of a 62-year-old pig breeder who lived in Normandy (France) and never traveled abroad. He used to eat fruits and vegetables from his own garden. His medical history was marked by a definite diagnosis of hereditary hemorrhagic telangiectasia (HHT) visceral arteriovenous malformations (AVMs). In December 2016, he was admitted to a general hospital because of an acute headache, confusion, and gait disorders. Physical examination revealed left ptosis, ataxia, dysarthria, and mucocutaneous telangiectasia. A brain magnetic resonance image (MRI) showed multiple parenchymal small gadolini-um-enhancing lesions with hypointense signals in T1-weighted sequences, associated with a large perilesional edema in fluid attenuated inversion recovery (FLAIR) sequences (Figure 1A and E). Cerebrospinal fluid (CSF) withdrawn on day 2 revealed a lymphocytic meningitis with 230 white cells/mm 3 , a protein content of 1g/L, and normal glycorrhachia. Suspected pyogenic brain abscesses were treated by cefotaxime and metronidazole. Blood and CSF cultures were sterile, and C-reactive protein was normal. Blood samples obtained for serological testing to detect Coxiella burnetii, Rickettsia spp., Bartonella henselae, Bartonella quintana, Brucella spp., Treponema pallidum, and HIV were negative. A second-step CSF analysis was negative for mycobacteria (polymerase chain reaction [PCR] and culture), Toxoplasma gondii (PCR), Cryptococcus spp., and Nocardia spp. At day 5, the patient's neurological status deteriorated, resulting in aphasia and right hemiplegia. Thoracic and abdominal CT and abdominal ultrasound (US) were normal. Albendazole and corticosteroid were added to the treatment because of a suspected neurocysticercosis (due to both his occupation and a consistent brain imaging presentation, although this condition is extremely rare in metropolitan France) or necrotic cerebral metastasis. The patient was referred to the Infectious Diseases Unit of the University Hospital of Caen, Normandy, on day 11. As serum and CSF serology for cysticercosis were negative, cor-ticosteroid and albendazole were stopped. A first brain biopsy (day 18) only showed inflammation consistent with an extra-abscess biopsy, leading to a second brain biopsy (day 30), which showed necrotic tissue with eosinophilic material composed of fragments of a laminated layer, intensely colored by the periodic acid-Schiff (PAS) stain and Grocott's methenamine silver stain (Figure 2). No germinative layer was noted. A tapeworm was suspected, but its genus could not be identified. The results of the bacteriological analyses of the brain tissue performed by direct examination, standard culture, universal bacterial PCR targeting the 16S rRNA gene, specific culture, fungal and myco-bacterial culture, and PCR of Mycobacterium spp. were negative. An exceptional case of autochthonous neurocysticercosi

Comparison of alcoholic chlorhexidine and povidone–iodine cutaneous antiseptics for the prevention of central venous catheter-related infection: a cohort and quasi-experimental multicenter study

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Procalcitonin algorithm to guide initial antibiotic therapy in acute exacerbations of COPD admitted to the ICU: a randomized multicenter study

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Characteristics and prognosis of bloodstream infection in patients with COVID-19 admitted in the ICU: an ancillary study of the COVID-ICU study

International audienceBackground Patients infected with the severe acute respiratory syndrome coronavirus 2 (SARS-COV 2) and requiring intensive care unit (ICU) have a high incidence of hospital-acquired infections; however, data regarding hospital acquired bloodstream infections (BSI) are scarce. We aimed to investigate risk factors and outcome of BSI in critically ill coronavirus infectious disease-19 (COVID-19) patients. Patients and methods We performed an ancillary analysis of a multicenter prospective international cohort study (COVID-ICU study) that included 4010 COVID-19 ICU patients. For the present analysis, only those with data regarding primary outcome (death within 90 days from admission) or BSI status were included. Risk factors for BSI were analyzed using Fine and Gray competing risk model. Then, for outcome comparison, 537 BSI-patients were matched with 537 controls using propensity score matching. Results Among 4010 included patients, 780 (19.5%) acquired a total of 1066 BSI (10.3 BSI per 1000 patients days at risk) of whom 92% were acquired in the ICU. Higher SAPS II, male gender, longer time from hospital to ICU admission and antiviral drug before admission were independently associated with an increased risk of BSI, and interestingly, this risk decreased over time. BSI was independently associated with a shorter time to death in the overall population (adjusted hazard ratio (aHR) 1.28, 95% CI 1.05–1.56) and, in the propensity score matched data set, patients with BSI had a higher mortality rate (39% vs 33% p = 0.036). BSI accounted for 3.6% of the death of the overall population. Conclusion COVID-19 ICU patients have a high risk of BSI, especially early after ICU admission, risk that increases with severity but not with corticosteroids use. BSI is associated with an increased mortality rate

Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome Associated with COVID-19: An Emulated Target Trial Analysis

International audienc