Effect of Noninvasive Ventilation vs Oxygen Therapy on Mortality Among Immunocompromised Patients With Acute Respiratory Failure: A Randomized Clinical Trial

IMPORTANCE

Noninvasive ventilation has been recommended to decrease mortality among immunocompromised patients with hypoxemic acute respiratory failure. However, its effectiveness for this indication remains unclear.

OBJECTIVE

To determine whether early noninvasive ventilation improved survival in immunocompromised patients with nonhypercapnic acute hypoxemic respiratory failure.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter randomized trial conducted among 374 critically ill immunocompromised patients, of whom 317 (84.7%) were receiving treatment for hematologic malignancies or solid tumors, at 28 intensive care units (ICUs) in France and Belgium between August 12, 2013, and January 2, 2015.

INTERVENTIONS

Patients were randomly assigned to early noninvasive ventilation (n = 191) or oxygen therapy alone (n = 183).

MAIN OUTCOMES AND MEASURES

The primary outcome was day-28 mortality. Secondary outcomes were intubation, Sequential Organ Failure Assessment score on day 3, ICU-acquired infections, duration of mechanical ventilation, and ICU length of stay.

RESULTS

At randomization, median oxygen flow was 9 L/min (interquartile range, 5-15) in the noninvasive ventilation group and 9 L/min (interquartile range, 6-15) in the oxygen group. All patients in the noninvasive ventilation group received the first noninvasive ventilation session immediately after randomization. On day 28 after randomization, 46 deaths (24.1%) had occurred in the noninvasive ventilation group vs 50 (27.3%) in the oxygen group (absolute difference, -3.2 [95% CI, -12.1 to 5.6]; P = .47). Oxygenation failure occurred in 155 patients overall (41.4%), 73 (38.2%) in the noninvasive ventilation group and 82 (44.8%) in the oxygen group (absolute difference, -6.6 [95% CI, -16.6 to 3.4]; P = .20). There were no significant differences in ICU-acquired infections, duration of mechanical ventilation, or lengths of ICU or hospital stays.

CONCLUSIONS AND RELEVANCE

Among immunocompromised patients admitted to the ICU with hypoxemic acute respiratory failure, early noninvasive ventilation compared with oxygen therapy alone did not reduce 28-day mortality. However, study power was limited.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01915719.

Comparative dynamics of the emergence of fluoroquinolone resistance in staphylococci from the nasal microbiota of patients treated with fluoroquinolones according to their environment

Fluoroquinolone-resistant staphylococci (FQRS) are primarily selected in the nasal microbiota during fluoroquinolone (FQ) treatment. To gain insight into the dynamics of the emergence of FQRS, 49 hospitalised patients (HPs) and 62 community patients (CPs) treated with FQs were studied. Nasal swabs were collected before (T0), at the end of (T1) and 1 month after (T2) FQ treatment. FQRS were identified by mass spectrometry. Antibiotic resistance was determined. Pre- and post-exposure staphylococci populations were compared phenotypically and by MLST to determine the origin of FQRS. At T0, 33/49 HPs (67%) and 24/62 CPs (39%) carried FQRS (OR=3.3, 95% CI: 1.4-7.9; P<0.001). Among patients with no FQRS at T0, 15/16 HPs (94%) and 16/38 CPs (42%) had FQRS detected at T1 and/or T2 (OR=19.6, 95% CI: 2.5-902; P<0.001). Among FQRS having emerged, co-resistance to meticillin was detected in 87% and 82% of HPs and CPs, respectively. No selection of resistance emerging from the initial microbiota was evidenced. FQRS showed decreased species diversity in favour of Staphylococcus haemolyticus and Staphylococcus epidermidis. As a consequence of FQ treatment, acquisition of FQRS in the nasal microbiota is frequent in the community and almost inevitable in hospitals. Acquisition from extranasal sites prevails. A restriction in species diversity in favour of more pathogenic and resistant species occurs. This highlights the major impact of FQ treatment on nasal microbiota, the role of the ecological environment in the emergence of FQRS, and the high-risk of dissemination of resistant staphylococci.

Mechanisms of antimicrobial resistance in Gram-negative bacilli

The burden of multidrug resistance in Gram-negative bacilli (GNB) now represents a daily issue for the management of antimicrobial therapy in intensive care unit (ICU) patients. In Enterobacteriaceae, the dramatic increase in the rates of resistance to third-generation cephalosporins mainly results from the spread of plasmid-borne extended-spectrum beta-lactamase (ESBL), especially those belonging to the CTX-M family. The efficacy of beta-lactam/beta-lactamase inhibitor associations for severe infections due to ESBL-producing Enterobacteriaceae has not been adequately evaluated in critically ill patients, and carbapenems still stands as the first-line choice in this situation. However, carbapenemase-producing strains have emerged worldwide over the past decade. VIM- and NDM-type metallo-beta-lactamases, OXA-48 and KPC appear as the most successful enzymes and may threaten the efficacy of carbapenems in the near future. ESBL- and carbapenemase-encoding plasmids frequently bear resistance determinants for other antimicrobial classes, including aminoglycosides (aminoglycoside-modifying enzymes or 16S rRNA methylases) and fluoroquinolones (Qnr, AAC(6′)-Ib-cr or efflux pumps), a key feature that fosters the spread of multidrug resistance in Enterobacteriaceae. In non-fermenting GNB such as Pseudomonas aeruginosa, Acinetobacter baumannii and Stenotrophomonas maltophilia, multidrug resistance may emerge following the sole occurrence of sequential chromosomal mutations, which may lead to the overproduction of intrinsic beta-lactamases, hyper-expression of efflux pumps, target modifications and permeability alterations. P. aeruginosa and A. baumannii also have the ability to acquire mobile genetic elements encoding resistance determinants, including carbapenemases. Available options for the treatment of ICU-acquired infections due to carbapenem-resistant GNB are currently scarce, and recent reports emphasizing the spread of colistin resistance in environments with high volume of polymyxins use elicit major concern.

Sucrose is an early modulator of the key hormonal mechanisms controlling bud outgrowth in Rosa hybrida

Sugar has only recently been identified as a key player in triggering bud outgrowth, while hormonal control of bud outgrowth is already well established. To get a better understanding of sugar control, the present study investigated how sugar availability modulates the hormonal network during bud outgrowth in Rosa hybrida. Other plant models, for which mutants are available, were used when necessary. Buds were grown in vitro to manipulate available sugars. The temporal patterns of the hormonal regulatory network were assessed in parallel with bud outgrowth dynamics. Sucrose determined bud entrance into sustained growth in a concentration-dependent manner. Sustained growth was accompanied by sustained auxin production in buds, and sustained auxin export in a DR5::GUS-expressing pea line. Several events occurred ahead of sucrose-stimulated bud outgrowth. Sucrose upregulated early auxin synthesis genes (RhTAR1, RhYUC1) and the auxin efflux carrier gene RhPIN1, and promoted PIN1 abundance at the plasma membrane in a pPIN1::PIN1-GFP-expressing tomato line. Sucrose downregulated both RwMAX2, involved in the strigolactone-transduction pathway, and RhBRC1, a repressor of branching, at an early stage. The presence of sucrose also increased stem cytokinin content, but sucrose-promoted bud outgrowth was not related to that pathway. In these processes, several non-metabolizable sucrose analogues induced sustained bud outgrowth in R. hybrida, Pisum sativum, and Arabidopsis thaliana, suggesting that sucrose was involved in a signalling pathway. In conclusion, we identified potential hormonal candidates for bud outgrowth control by sugar. They are central to future investigations aimed at disentangling the processes that underlie regulation of bud outgrowth by sugar.

Light Signaling in Bud Outgrowth and Branching in Plants

Branching determines the final shape of plants, which influences adaptation, survival and the visual quality of many species. It is an intricate process that includes bud outgrowth and shoot extension, and these in turn respond to environmental cues and light conditions. Light is a powerful environmental factor that impacts multiple processes throughout plant life. The molecular basis of the perception and transduction of the light signal within buds is poorly understood and undoubtedly requires to be further unravelled. This review is based on current knowledge on bud outgrowth-related mechanisms and light-mediated regulation of many physiological processes. It provides an extensive, though not exhaustive, overview of the findings related to this field. In parallel, it points to issues to be addressed in the near future.

Ventilator-associated pneumonia due to carbapenem-resistant Gram-negative bacilli in an intensive care unit without carbapenemase-producing Enterobacteriaceae or epidemic Acinetobacter baumannii

Risk factors for ventilator-associated pneumonia (VAP) caused by carbapenem-resistant Gram-negative bacilli (CR-GNB) have rarely been evaluated in intensive care units (ICU) without epidemic carbapenemase-producing Acinetobacter baumannii or Enterobacteriaceae. We addressed this issue in a cohort of 141 patients (previous antimicrobial exposure, n = 131) with a first episode of VAP in a medico-surgical ICU. Twenty-six VAP (18.4%) involved a CR-GNB (Pseudomonas aeruginosa, n = 14, Stenotrophomonas maltophilia, n = 11, and A. baumannii, n = 1), without previous carbapenem exposure in 12 (46.1%) cases. GNB resistant to all β-lactams except carbapenems were equally isolated in CR-GNB VAP (co-infections, 23%) and other episodes (30%). Previous exposure to aminoglycosides (odds ratio (OR) 1.14 per day, 95% confidence interval (CI) 1.02-1.30, p = 0.02) and the number of antimicrobial classes used before VAP (OR 1.38 per class, 95% CI 1.10-1.73, p = 0.006) were the only independent predictors of CR-GNB. These results suggest that the empirical use of a carbapenem-colistin combination should be evaluated in late-onset VAP following broad-spectrum antimicrobial exposure.

Determination of toxic elements (mercury, cadmium, lead, tin and arsenic) in fish and shellfish samples. Risk assessment for the consumers

Although fish intake has potential health benefits, the presence of metal contamination in seafood has raised public health concerns. In this study, levels of mercury, cadmium, lead, tin and arsenic have been determined in fresh, canned and frozen fish and shellfish products and compared with the maximum levels currently in force. In a further step, potential human health risks for the consumers were assessed. A total of 485 samples of the 43 most frequently consumed fish and shellfish species in Andalusia (Southern Spain) were analyzed for their toxic elements content. High mercury concentrations were found in some predatory species (blue shark, cat shark, swordfish and tuna), although they were below the regulatory maximum levels. In the case of cadmium, bivalve mollusks such as canned clams and mussels presented higher concentrations than fish, but almost none of the samples analyzed exceeded the maximum levels. Lead concentrations were almost negligible with the exception of frozen common sole, which showed median levels above the legal limit. Tin levels in canned products were far below the maximum regulatory limit, indicating that no significant tin was transferred from the can. Arsenic concentrations were higher in crustaceans such as fresh and frozen shrimps. The risk assessment performed indicated that fish and shellfish products were safe for the average consumer, although a potential risk cannot be dismissed for regular or excessive consumers of particular fish species, such as tuna, swordfish, blue shark and cat shark (for mercury) and common sole (for lead).

Delayed aortic dissection after transcatheter aortic valve implantation

In selected high-risk patients with aortic stenosis, transcatheter aortic valve implantation (TAVI) can provide comparable functional improvement and early survival after surgical aortic valve replacement. However, the long-term outcome after TAVI is still to be determined and the occurrence of aortic dissection has not been systematically reported. Herein, a case is presented of delayed aortic dissection and rupture several months after an uneventful TAVI in a patient with bicuspid aortic valve stenosis.

Personal decision-making criteria related to seasonal and pandemic A(H1N1) influenza-vaccination acceptance among French healthcare workers

BACKGROUND

Influenza-vaccination rates among healthcare workers (HCW) remain low worldwide, even during the 2009 A(H1N1) pandemic. In France, this vaccination is free but administered on a voluntary basis. We investigated the factors influencing HCW influenza vaccination.

METHODS

In June-July 2010, HCW from wards of five French hospitals completed a cross-sectional survey. A multifaceted campaign aimed at improving vaccination coverage in this hospital group was conducted before and during the 2009 pandemic. Using an anonymous self-administered questionnaire, we assessed the relationships between seasonal (SIV) and pandemic (PIV) influenza vaccinations, and sociodemographic and professional characteristics, previous and current vaccination statuses, and 33 statements investigating 10 sociocognitive domains. The sociocognitive domains describing HCWs' SIV and PIV profiles were analyzed using the classification-and-regression-tree method.

RESULTS

Of the HCWs responding to our survey, 1480 were paramedical and 401 were medical with 2009 vaccination rates of 30% and 58% for SIV and 21% and 71% for PIV, respectively (p<0.0001 for both SIV and PIV vaccinations). Older age, prior SIV, working in emergency departments or intensive care units, being a medical HCW and the hospital they worked in were associated with both vaccinations; while work shift was associated only with PIV. Sociocognitive domains associated with both vaccinations were self-perception of benefits and health motivation for all HCW. For medical HCW, being a role model was an additional domain associated with SIV and PIV.

CONCLUSIONS

Both vaccination rates remained low. Vaccination mainly depended on self-determined factors and for medical HCW, being a role model.

The "Swiss Statement": who knows about it? How do they know? What are its effects on people living with HIV/AIDS?

The publication of the "Swiss Statement" in 2008 shook the international HIV prevention and advocacy scene. HIV behavioral research has provided us with some studies focusing on the potential changes that new prevention strategies can produce, but results are not conclusive. Besides, there is a lack of data concerning awareness of these kinds of prevention strategies on real-life settings, studying mainly the behavior of people recruited in different types of trials (e.g., circumcision, pre and post-exposure prophylaxis). The present study aims to (1) identify the factors associated with awareness of the "Swiss Statement" among PLWHA, (2) determine in which setting they became aware of it, and (3) look for potential, behavioral, and/or emotional changes as a consequence of this awareness. In order to achieve these three objectives, we used the data collected by a community-based survey called "HIV, Hepatitis and you." In order to determine the factors associated with the awareness of the Swiss Statement, univariate and multivariate logistic regression were performed. Main results show that among the 997 HIV-positive people answering the questionnaire, 57% knew about the Swiss Statement, and that their main source of information was the associative setting, while 30% declared having found out about it from their doctor. As for the factors associated with the awareness of the Swiss Statement, we found that the following variables were significantly associated with such awareness: living in stable housing, having a CD4 count above 350 cell/mm(3), having an undetectable viral load, being in contact with a HIV-solidarity network, feeling of belonging to the LGBT community, and filling out the questionnaire online. The results of this study point out that interventions addressed to improve access to health-related information for PLWHA facing socioeconomical difficulties and isolation are strongly needed.

The ERECTA gene controls spatial and temporal patterns of epidermal cell number and size in successive developing leaves of Arabidopsis thaliana

BACKGROUND AND AIMS

ERECTA has been identified as a pleiotropic regulator of developmental and physiological processes in Arabidopsis thaliana. Previous work demonstrated a role for ERECTA in the control of compensation between epidermal cell expansion and division in leaves.

METHODS

In this work, spatial and temporal analyses of epidermal cell division and expansion were performed on successive developing vegetative leaves of Arabidopsis thaliana in both ERECTA and erecta lines, LER and Ler, respectively, to understand how the ERECTA gene regulates compensation between these two processes.

KEY RESULTS

The loss of ERECTA function leads to a low cell expansion rate in all zones of a leaf and in all successive leaves of a plant. This low cell expansion rate is counterbalanced by an increase in the duration of cell division. As a consequence, the ERECTA mutation eliminates the tip to base cellular gradient generally observed in the leaf epidermis and also flattens the heteroblastic changes in epidermal cell area and number within a rosette. Ablation of floral buds eliminates the heteroblastic changes in cellular patterns in an ERECTA-dependent manner.

CONCLUSIONS

The results provide a detailed description of changes in leaf growth dynamics and cellular variables in both LER and Ler. Altogether they suggest that ERECTA influences leaf cellular development in relation to whole plant ontogeny.

Secular trends and dynamics of hospital associated methicillin-resistant Staphylococcus aureus

We performed an 11-year retrospective analysis of consecutive nonduplicate methicillin-resistant Staphylococcus aureus (MRSA) clinical isolates in two neighbouring hospitals in the Paris area. MRSA isolates were classified according to resistance (R) to fluoroquinolones (Fq), kanamycin (K), tobramycin (T) and gentamicin (G). The yearly number of MRSA isolates (3446 in total) decreased, from approximately 350 in 1997–2002 to 212 in 2007. Four patterns (P) were found: P1 (KTGFq R, n = 776), P2 [KTFq R; G susceptible (S), n = 1630], P3 (Fq R; KTG S, n = 397) and P4 (Fq S; any KTG susceptibility, n = 201). P1 predominated in 1997 (183 isolates) then dropped sharply (nine in 2007); P2 and P4 remained stable over time; and P3 increased from 13 isolates in 1997 to 72 in 2007. Patterns were significantly and positively associated with several variables, independently of the year of collection: P1, age < 80 years, male gender, intensive care unit stay, and hospital onset; P3, age > 80 years and stay in intermediate or long-term care wards; and P4, age < 40 years, stay in an obstetric ward, and imported cases. Molecular typing of 79 isolates in 2005 and 2007 using multilocus sequence typing, spa type, and SCCmec showed that P1, P2 and P3 isolates were mainly clonal, whereas P4 isolates were more diverse. P1 comprised mainly ST247-I isolates, P2 mainly ST8-IVc, and P3 mainly ST8-IVc and ST5-VI. In conclusion, the epidemiology of MRSA in Paris is changing rapidly at the local level, with phenotypically defined clones being substituted by others, with associations existing between changes in specific patient populations or circumstances.

[Multi-drug resistant Pseudomonas aeruginosa: towards a therapeutic dead end?]

Pseudomonas aeruginosa is a major hospital-associated pathogen that can cause severe infections, most notably in patients with cystic fibrosis or those hospitalized in intensive care units. In this context, the current increase in incidence of multi-drug resistant (MDR) isolates of P. aeruginosa (MDRPA) raises serious concerns. MDR in P. aeruginosa is defined as the resistance to 3 or 4 of the following antibiotic classes: penicillins/cephalosporins/monobactams, carbapenems, aminoglycosides, and fluoroquinolones. These strains constantly cumulate several resistance mechanisms as a consequence of multiple genetic events, i.e., chromosomal mutations or horizontal transfers of resistance genes. Involved mechanisms may include active efflux, impermeability resulting from porins loss, plasmid-encoded b-lactamases/carbapenemases or aminoglycosides-modifying enzymes, and enzymatic or mutation-associated changes in antibiotics targets. Antibiotic selection pressure represents the leading risk factor for MDRPA acquisition. Colistin (polymyxin E) remains active on virtually all MDRPA isolates, and increasingly appears as the last available option to treat infections caused by these strains. However, the emergence of colistin resistance has been reported in P. aeruginosa, which may announce the spread of pan-resistant strains in a close future.