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Biomedical subjects

B Gachot

Publications and source records attributed to B Gachot.

At least 37 records · Page 2Linked to original sources
PubMed1997

Shock complicating severe falciparum malaria in European adults.

OBJECTIVE: To study adult patients with severe falciparum malaria who developed shock. DESIGN: Retrospective study from 1987 to 1993. SETTING: Medical intensive care unit in a university hospital. PATIENTS: 14 patients admitted with severe falciparum malaria who developed shock. All received intravenous quinine. MEASUREMENTS AND RESULTS: The mean Simplified Acute Physiology Score II was 59.5 +/- 7.1; 2.6 +/- 0.4 criteria defining severe disease were present on admission in 12 patients; and initial parasitemia was 21 +/- 6%. Twelve patients received inotropic drugs. Pulmonary artery catheterization showed the following results in 7 patients: mean arterial pressure 57 +/- 4 mmHg; pulmonary artery occlusion pressure 11 +/- 1 mmHg; cardiac index 5.5 +/- 0.91.min-1.m-2, and systemic vascular resistance index 783 +/- 122 dyne.s.cm-5.m-2. Seven patients had evidence of bacterial infection at the time of shock. Of the 7 deaths (50%), 5 were due to shock, with documented bacterial infection in all patients and persistent parasitemia in 4. CONCLUSIONS: Shock complicating severe falciparum malaria in adults is associated with peripheral vasodilation and carries a poor prognosis. In falciparum malaria with shock, bacterial coinfection should be suspected immediately and treated empirically with broad-spectrum antibiotics. Nevertheless, Plasmodium falciparum may contribute directly or indirectly to the onset of shock.

Adult↗
PubMed1997

Septic shock in patients with the acquired immunodeficiency syndrome.

OBJECTIVE: To evaluate the prognosis of patients with septic shock admitted to an intensive care unit (ICU), according to their HIV serostatus. DESIGN: Retrospective study. SETTING: Medical ICU of a university hospital. PATIENTS: 76 patients with septic shock admitted to the same ICU, of whom 28 were HIV positive and 48 were HIV negative. MEASUREMENTS AND RESULTS: Severity scores, number and type of organ failures, and survival rates were assessed in the two groups of patients. Glasgow Coma Scale and general severity scores [Acute Physiology and Chronic Health Evaluation II and Simplified Acute Physiology Score (SAPS)] were significantly worse in HIV-infected patients. The total number of organ failures was also higher in the HIV-positive group: 3.7 +/- 0.2 vs 3.1 +/- 0.2 in the HIV-negative group (p < 0.001). On day 28, 21 (46%) HIV-negative patients were dead compared to 26 (93%) patients in the HIV-positive group (p < 0.001). In the multivariate analysis, HIV infection was an independent risk factor for mortality, as were the SAPS score, use of mechanical ventilation, and the McCabe score. CONCLUSIONS: This study reports a considerable excess mortality in HIV-infected patients with septic shock. Although severity of illness was clearly much more pronounced in HIV-positive patients, retroviral infection was independently associated with death. Improving survival in HIV-positive patients with septic shock may require earlier diagnosis and treatment of the causative infection.

AIDS-Related Opportunistic Infections↗
PubMed1997

Prognostic factors for neutropenic patients in an intensive care unit: respective roles of underlying malignancies and acute organ failures.

The admission of neutropenic patients to an intensive care unit (ICU) is still controversial, especially if mechanical ventilation is required. To avoid useless stays in ICU, the evaluation of the respective role of the underlying malignancy and acute organ failures might be useful for better definition of the categories of patients who could benefit from aggressive ICU support. For this purpose, we carried out a retrospective study of the charts of 107 consecutive neutropenic patients admitted to an ICU in a comprehensive cancer centre over a four-year period. The following characteristics were recorded within 24 h of admission: patient data, characteristics of neutropenia and the underlying malignancy, the type and number of organ system failures (OSFs) and simplified acute physiological scores (SAPS and SAPS II). The impact of each variable on outcome in the ICU was studied by univariate and multivariate (logistic regression) analysis. 59 patients died in the ICU (mortality rate: 55%). Patients with a haematological malignancy (n = 57, 53%) were more likely to experience respiratory failure, an underlying malignancy deemed rapidly fatal, and to have longer lasting neutropenia than patients with a solid tumour (n = 50, 47%). However, the mortality rate did not differ in the two groups (haematological malignancy 61% versus solid tumour 48%, p = 0.16). Respiratory and cardiovascular organ failure (p < 0.001 for both) correlated with mortality in the ICU. In the multiple logistic regression model, only the number of organ system failures and respiratory failure remained predictive of ICU mortality. In conclusion, the characteristics of the underlying malignancy are not relevant when deciding whether or not neutropenic patients should be admitted to an ICU. The main risk factors for death in an ICU are the number of organ failures on admission, and among them the presence of respiratory failure.

Adult↗
PubMed1997

[Peritoneal carcinosis treated by complete excision and immediate postoperative intra-peritoneal chemotherapy. Phase II study in 54 patients].

OBJECTIVES: The short term prognosis of peritoneal carcinomatosis whose classical treatment is intravenous chemotherapy, is poor (mean survival of 6 months). The aim of this study was to report the results of a phase II prospective study in which peritoneal carcinomatosis was managed with complete reductive surgery associated with treatment of the residual microscopic disease with immediate intraperitoneal postoperative chemotherapy. PATIENTS AND METHODS: Fifty-four patients with peritoneal carcinomatosis from miscellaneous origins, were treated between January 1993 and April 1996. Major peritoneal carcinomatosis was important, clinically evident, but without extraperitoneal localization in 29 cases. It was moderate, fortuitously discovered during a laparotomy for an extraperitoneal recurrence in 25 cases. Immediate intraperitoneal postoperative chemotherapy was carried out continuously during 5 days, with 900 ml/m2 of ringer lactate, with either mitomycine C and 5-fluorouracil, or doxorubicin and platinum, according to histology. The treatment was complete in 91% of cases. RESULTS: Three patients died during the hospitalization (5.5%), and a high morbidity (61%) was observed, with 35% intra-abdominal complications necessitating surgery in 13% of the patients. The postoperative complications were correlated with the extension of the cytoreductive surgery (P < 0.001). After a mean follow-up of 12.3 months, 13 patients died. The 2-year survival rate was 50%. Survival was related to the importance of the peritoneal carcinomatosis (P < 0.01) and was identical for patients with isolated peritoneal carcinomatosis and for patients with moderate peritoneal carcinomatosis associated with resected extra-peritoneal disease. The incidence of recurrence of peritoneal carcinomatosis was 30% at 2 years, showing the efficiency of this new procedure to treat peritoneal carcinomatosis. CONCLUSIONS: Complete cytoreductive surgery with immediate intraperitoneal postoperative chemotherapy is a promising treatment of peritoneal carcinomatosis. However it appears that: a) it is a difficult treatment for patients and for physicians, b) its efficiency will be asserted only with a randomized study (currently ongoing), that only allows to suppress selection bias, c) it is able to cure some groups of peritoneal carcinomatosis (probably 20%), that will be difficult to identify, and d) improvement of immediate intraperitoneal postoperative chemotherapy is possible (mainly with hyperthermia). The main advantage of immediate intraperitoneal postoperative chemotherapy is that, after proving its efficiency, easy widespread use will be assured.

Adult↗
PubMed1997

[Optimum quinine therapy in falciparum malaria attacks contracted in Africa].

A review about the use of quinine for uncomplicated falciparum malaria contracted in Africa is proposed. The dose of 8 mg/kg of quinine base 3 times a day seems to be admitted by all. On the other way, the duration of treatment fluctuates from 2 to 10 days without evidence of difference in efficacy between 3, 5 and 7 days. The pharmacodynamic and pharmacokinetic properties of quinine are reviewed and suggest that 3, 5 and 7 days are efficient at least on, respectively, 1, 2 and 3 parasite cycles and suggest that a five day treatment may be curative for all kind of patients infested with a quinine-sensitive strain of P. falciparum in Africa.

Africa↗
PubMed1996

Nosocomial cerebral aspergillosis: a report of 3 cases.

Cerebral aspergillosis carries a mortality rate close to 100%, especially in immunocompromised patients. We describe 3 patients who contracted cerebral aspergillosis after neurosurgery, 2 of whom survived after exhaustive surgical treatment and medical treatment with high doses of amphotericin B (once liposomal), 5-fluorocytosine and itraconazole. We review the few non-fatal cases of cerebral aspergillosis reported. We consider that surgical excision must be complete and repeated if necessary, always in combination with medical treatment.

Adolescent↗
PubMed1995

[Physiopathology of cerebral malaria].

Although simple animal models relevant to human disease are lacking, many recent clinical and experimental studies have focused on the pathophysiology of cerebral malaria. Evidence of sequestration of parasitized erythrocytes is found in the cerebral capillaries of patients dying from cerebral malaria. Cytoadherence of parasitized red blood cells to endothelium is an essential process. However, no correlation was found between in vitro cytoadherence of clinical isolates and the presence of cerebral symptoms. Rosetting is defined by the agglutination of nonparasitized erythrocytes around red cells containing mature forms of the parasite, and probably contributes to the intravascular sequestration of erythrocytes. This phenomenon occurs in vitro, and isolates from patients with cerebral malaria appear to have increased rosetting properties. The excellent recovery of most survivors, even after a deep and lengthy coma, suggests that microvascular obstruction causing cerebral hypoxia is not the main factor contributing to cerebral dysfunction. Raised intracranial pressure with or without cerebral oedema is common in children, and contributes to mortality. The nonspecific immune inflammatory response of the host to the malarial parasite, with release of various mediators, seems to be of paramount importance. Among cytokines, tumor necrosis factor (TNF) appears to be associated with mortality; although plasma levels of TNF are not correlated with neurological dysfunction, this does not exclude a role of this cytokine at a paracrine level. Cytoadherence of parasitized red blood cells to endothelium and concomitant activation of mononuclear blood cells may be responsible for a local synthesis of cytokines, or even neurotransmitters that remain to be identified.

Adolescent↗
PubMed1995

Early predictors of outcome for HIV patients with neurological failure.

OBJECTIVE: To carry out a descriptive study of human immunodeficiency virus (HIV)-infected patients admitted to an intensive care unit (ICU) with neurological failure and to identify parameters that are predictive of death within 3 months. DESIGN: Case series study. POPULATION AND SETTING: A total of 84 consecutive HIV-infected patients admitted to an infectious disease ICU in a university hospital for neurological failure. A thorough clinical, laboratory, and brain computed tomography (CT) scan workup was done within 48 hours of admission. MAIN RESULTS: The mean (+/- SD) CD4+ lymphocyte count was 0.067 (+/- 0.086) x 10(9)/L. Mechanical ventilation was necessary within 48 hours of admission in 67 cases (80%). The brain CT scan revealed abscesses in 51 patients (61%). The abscesses were attributed to probable toxoplasmosis in 47 patients. A total of 57 patients died, yielding a 3-month survival rate of 32%. By the log-rank test, the following factors were predictive of death within 3 months of admission to the ICU: Glasgow Coma Scale score less than 7 (P = .01), signs of brain stem involvement (P = .001), and need for mechanical ventilation in the 48 hours after admission (P = .02). In a Cox model, only Glasgow Coma Scale score less than 7 (P = .006) and clinical signs of brain stem involvement (P = .02) were predictive of death within 3 months of admission to the ICU. CONCLUSIONS: Despite a thorough examination, no initial HIV-specific parameters were identified as predictive of death. The prognostic factors found simply reflected the severity of neurological involvement in the various etiologies.

AIDS Dementia Complex↗
PubMed1995

Short-term effects of methylene blue on hemodynamics and gas exchange in humans with septic shock.

OBJECTIVE: The aim of this study was to investigate the acute effects of methylene blue (MB), an inhibitor of the L-arginine nitric oxide pathway, in patients with septic shock. DESIGN: A prospective, open, single-dose study. SETTING: The medical ICU of a university hospital. PATIENTS: Six patients with severe septic shock. INTERVENTIONS: Complete hemodynamic values were recorded before and 20 min after the infusion of intravenous MB (3 mg kg(-1)). Arterial pressure was then monitored during the next 24 h or until death. MEASUREMENTS AND RESULTS: Methylene blue increased the mean arterial pressure from 69.7 +/- 4.5 to 83.7 +/- 5.1 mmHg (p = 0.028) and the mean pulmonary artery pressure, from 34.3 +/- 7.2 to 38.7 +/- 8.0 mmHg (p = 0.023). Systemic vascular resistance index was increased from 703.1 +/- 120.6 to 903.7 +/- 152.2 dyne.s.cm(-5).m(-2) (p = 0.028) and pulmonary vascular resistance index, from 254.6 +/- 96.9 to 342.2 +/- 118.9 dyne.s.cm(-5) .m(-2) (p = 0.027). The PaO2/FIO2 decreased from 229.2 +/- 54.4 to 162.2 +/- 44.1 mmHg (p = 0.028), without significant modification of intrapulmonary shunting. Heart rate, cardiac index, right atrial pressure, DO2, VO2, oxygen extraction and arterial lactate were essentially unchanged. Sequential measurements of arterial pressure demonstrated a return to baseline level in 2-3 h. All but one patients died, three in shock and two in multiple organ failure. CONCLUSIONS: MB induces systemic and pulmonary vasoconstriction in patients with septic shock, without significant decrease in cardiac index. The worsening of arterial oxygenation following MB injection may limit its use in patients with the adult respiratory distress syndrome. Larger studies are required to determine whether MB improves the outcome of patients with septic shock.

Adult↗
PubMed1995

[Severe forms of pseudomembranous colitis caused by Clostridium difficile].

Clostridium difficile causes a broad spectrum of enteric diseases in humans, ranging from mild antibiotic-associated diarrhoea to more severe pseudomembranous colitis. The authors report four cases of life-threatening pseudomembranous colitis with haemodynamic changes. Infection due to Clostridium difficile should be kept in mind whenever a patient undergoing antibiotic therapy develops a symptomatology of an acute abdomen.

Abdomen, Acute↗
PubMed1995

Acute lung injury complicating imported Plasmodium falciparum malaria.

STUDY OBJECTIVE: To characterize adult patients with acute lung injury complicating severe imported Plasmodium falciparum malaria. DESIGN AND SETTING: Retrospective study of patients with severe P falciparum malaria admitted to the medical ICU of a university hospital infectious diseases department. PATIENTS: Forty adults with complicated malaria, with (group 1, 12 patients) or without (group 2, 28 patients) acute lung injury. RESULTS: Patients with acute lung injury had a higher simplified acute physiology score on admission (24.2 +/- 3.2 vs 13.7 +/- 0.7 in group 2, p < 0.0001) and a longer time interval to adequate antimalarial therapy (8.8 +/- 2.5 vs 4.9 +/- 0.6 days in group 2, p = 0.046). Of the nine group 1 patients given mechanical ventilation, eight had a PaO2/FIO2 < or = 200 mm Hg. Two patients with moderate hypoxemia received oxygen through a nasal tube and one received continuous positive airway pressure via a face mask. Acute renal failure, unrousable coma, metabolic acidosis, and shock were significantly more common among group 1 patients. The number of complications of malaria was significantly higher in patients with acute lung injury (4.7 +/- 0.5 vs 1.6 +/- 0.1 in group 2, p < 0.0001). Five patients, including four with acute lung injury, had evidence of bacterial infection (pneumonia or primary bacteremia) at ICU admission. Four patients with acute lung injury died (33%) vs one patient without acute lung injury (4%, p = 0.022). CONCLUSIONS: Acute lung injury is more likely to occur in patients with extremely severe, multisystemic P falciparum malaria. In patients with acute lung injury and septic shock, bacterial coinfection should be suspected and treated empirically since it contributes substantially to early mortality.

Acidosis↗
PubMed1995

Overwhelming myocarditis due to Fusarium oxysporum following bone marrow transplantation.

Disseminated infection by Fusarium is being increasingly reported in immunocompromised patients. We report the first case of Fusarium oxysporum disseminated infection with well-documented fungal myocarditis. Despite antifungal therapy and hematologic recovery, the patient died in cardiogenic shock, myocardial involvement clearly contributing to the fatal outcome.

Anemia, Aplastic↗