1
|
Poli S, Sciorio F, Piacentini G, Pietrobelli A, Pecoraro L, Pieropan S. Acute Respiratory Failure in Autoimmune Rheumatic Diseases: A Review. J Clin Med 2024; 13:3008. [PMID: 38792549 PMCID: PMC11122618 DOI: 10.3390/jcm13103008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/08/2024] [Accepted: 05/17/2024] [Indexed: 05/26/2024] Open
Abstract
This review examines respiratory complications in autoimmune rheumatic diseases within intensive care units (ICUs). The respiratory system, primarily affected in diseases like rheumatoid arthritis, systemic lupus erythematosus, and scleroderma, often leads to respiratory failure. Common manifestations include alveolar hemorrhage, interstitial fibrosis, and acute respiratory distress syndrome. Early recognition and treatment of non-malignant conditions are crucial to prevent rapid disease progression, with ICU mortality rates ranging from 30% to 60%. Delayed immunosuppressive or antimicrobial therapy may result in organ system failure. Collaboration with rheumatic specialists is vital for accurate diagnosis and immediate intervention. Mortality rates for rheumatic diseases in the ICU surpass those of other conditions, underscoring the need for specialized care and proactive management. The review emphasizes comprehensive assessments, distinguishing disease-related complications from underlying issues, and the importance of vigilant monitoring to enhance patient outcomes.
Collapse
Affiliation(s)
| | | | | | | | - Luca Pecoraro
- Pediatric Clinic, Department of Surgical Sciences, Dentistry, Pediatrics and Gynecology, University of Verona, 37126 Verona, Italy
| | | |
Collapse
|
2
|
Dumas G, Arabi YM, Bartz R, Ranzani O, Scheibe F, Darmon M, Helms J. Diagnosis and management of autoimmune diseases in the ICU. Intensive Care Med 2024; 50:17-35. [PMID: 38112769 DOI: 10.1007/s00134-023-07266-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/01/2023] [Indexed: 12/21/2023]
Abstract
Autoimmune diseases encompass a broad spectrum of disorders characterized by disturbed immunoregulation leading to the development of specific autoantibodies, resulting in inflammation and multiple organ involvement. A distinction should be made between connective tissue diseases (mainly systemic lupus erythematosus, systemic scleroderma, inflammatory muscle diseases, and rheumatoid arthritis) and vasculitides (mainly small-vessel vasculitis such as antineutrophil cytoplasmic antibody-associated vasculitis and immune-complex mediated vasculitis). Admission of patients with autoimmune diseases to the intensive care unit (ICU) is often triggered by disease flare-ups, infections, and organ failure and is associated with high mortality rates. Management of these patients is complex, including prompt disease identification, immunosuppressive treatment initiation, and life-sustaining therapies, and requires multi-disciplinary involvement. Data about autoimmune diseases in the ICU are limited and there is a need for multicenter, international collaboration to improve patients' diagnosis, management, and outcomes. The objective of this narrative review is to summarize the epidemiology, clinical features, and selected management of severe systemic autoimmune diseases.
Collapse
Affiliation(s)
- Guillaume Dumas
- Medical Intensive Care Unit, Service de Médecine Intensive-Réanimation, CHU Grenoble-Alpes, Université Grenoble-Alpes, INSERM, U1042-HP2, Grenoble, France.
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences Riyadh, Riyadh, Kingdom of Saudi Arabia
| | - Raquel Bartz
- Department of Anesthesia, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Otavio Ranzani
- Barcelona Institute for Global Health, ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Pulmonary Division, Faculdade de Medicina, Heart Institute, InCor, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Franziska Scheibe
- Department of Neurology and Experimental Neurology, Charité- Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Michaël Darmon
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, Famirea Study Group, ECSTRA Team, and Clinical EpidemiologyUMR 1153, Center of Epidemiology and Biostatistics, Sorbonne Paris Cité, CRESS, INSERM, Université Paris Cité, Paris, France
| | - Julie Helms
- Faculté de Médecine, Service de Médecine Intensive-Réanimation, Université de Strasbourg (UNISTRA), Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, 1 Place de L'Hôpital, Strasbourg, France
| |
Collapse
|
3
|
Schneeweiss-Gleixner M, Hillebrand C, Jaksits S, Fries J, Zauner M, Heinz G, Sengölge G, Staudinger T, Zauner C, Aletaha D, Machold KP, Schellongowski P, Bécède M. Characteristics and outcome of critically ill patients with systemic rheumatic diseases referred to the intensive care unit. RMD Open 2023; 9:e003287. [PMID: 38030230 PMCID: PMC10689389 DOI: 10.1136/rmdopen-2023-003287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 11/07/2023] [Indexed: 12/01/2023] Open
Abstract
OBJECTIVES Patients with systemic rheumatic diseases (SRDs) are at risk of admission to the intensive care unit (ICU). Data concerning these critically ill patients are limited to few retrospective studies. METHODS This is a single-centre retrospective study of patients with SRDs admitted to an ICU at the Vienna General Hospital between 2012 and 2020. Single-predictor and multiple logistic regression analysis was performed to identify potential outcome determinants. RESULTS A total of 144 patients accounting for 192 ICU admissions were included. Connective tissue diseases (CTDs), vasculitides and rheumatoid arthritis were the most common SRDs requiring ICU admission. Leading causes for ICU admission were respiratory failure and shock, as reflected by a high number of patients requiring mechanical ventilation (60.4%) and vasopressor therapy (72.9%). Overall, 29.2% of admissions were due to SRD-related critical illness. In 70.8% patients, co-existent SRD not responsible for the acute critical illness was documented. When comparing these subgroups, CTDs and vasculitides had a higher frequency in the patients with SRD-related critical illness. In a significantly higher proportion of patients in the SRD-related subgroup, diagnosis of SRD was made at the ICU. ICU and 6-month mortality in the overall population was 20.3% and 38.5%, respectively. Age, glucocorticoid therapy prior to hospital admission and disease severity were associated with poor outcome. CONCLUSIONS In this study, respiratory failure was the leading cause of ICU admission as reflected by high rates of required mechanical ventilation. Despite considerable severity of critical illness, survival rates were comparable to a general ICU population.
Collapse
Affiliation(s)
- Mathias Schneeweiss-Gleixner
- Clinical Division of Gastroenterology and Hepatology, Department of Medicine III, Intensive Care Unit 13.h1, Medical University of Vienna, Vienna, Austria
| | - Caroline Hillebrand
- Clinical Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Stephanie Jaksits
- Clinical Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Jonathan Fries
- Department of Developmental and Educational Psychology, Faculty of Psychology, University of Vienna, Vienna, Austria
| | - Michael Zauner
- Clinical Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gottfried Heinz
- Clinical Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Gürkan Sengölge
- Clinical Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Staudinger
- Intensive Care Unit 13.i2, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Christian Zauner
- Clinical Division of Gastroenterology and Hepatology, Department of Medicine III, Intensive Care Unit 13.h1, Medical University of Vienna, Vienna, Austria
| | - Daniel Aletaha
- Clinical Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Klaus P Machold
- Clinical Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Peter Schellongowski
- Intensive Care Unit 13.i2, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Manuel Bécède
- Clinical Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Lower Austrian Centre for Rheumatology, Department of Medicine II, State Hospital Stockerau, Stockerau, Austria
- Karl Landsteiner Institute for Clinical Rheumatology, Stockerau, Austria
| |
Collapse
|
4
|
Yin L, Min J, Zhong L, Shen Q. The correlation between red cell distribution width to albumin ratio and all-cause mortality in critically ill patients with rheumatic diseases: a population-based retrospective study. Front Med (Lausanne) 2023; 10:1199861. [PMID: 37908850 PMCID: PMC10614050 DOI: 10.3389/fmed.2023.1199861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 09/29/2023] [Indexed: 11/02/2023] Open
Abstract
Background Patients with rheumatic diseases have an increased likelihood of being admitted to the intensive care unit (ICU), highlighting the importance of promptly identifying high-risk individuals to enhance prognosis. This study aimed to assess the correlation of red blood cell distribution width to albumin ratio (RAR) with the 90-days and 360-days survival rates among critically ill rheumatic patients. Methods Adult rheumatic patients admitted to the ICU from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database were included. The participants were categorized into two groups, survivors (n = 436) and non-survivors (n = 192), based on their 90-days survival outcome. The population was further classified into tertiles using RAR values, with RAR < 4.63 (n = 208), 4.63-6.07 (n = 211), and > 6.07 (n = 209). Kaplan-Meier curves were utilized to evaluate the cumulative survival rates at 90-days and 360-days. The association between RAR and mortality was assessed using restricted cubic splines (RCS) and multivariate Cox regression analysis. Additional subgroup analyses and sensitivity analyses were conducted to further explore the findings. Receiver operating characteristic (ROC) curves were generated to evaluate the predictive performance of RAR. Results This study involved 628 critically ill patients with rheumatic diseases, and they had an all-cause mortality of 30.57% at 90-days and 38.69% at 360-days. Kaplan-Meier analysis showed a gradual decrease in both 90-days and 360-days cumulative survival with increasing RAR (χ2 = 24.400, p < 0.001; χ2 = 35.360, p < 0.001). RCS revealed that RAR was linearly related to 90-days and 360-days all-cause mortality risk for critically ill patients with rheumatic diseases (χ2 = 4.360, p = 0.225; χ2 = 1.900, p = 0.594). Cox regression analysis indicated that elevated RAR (> 6.07) was significantly correlated with mortality. The ROC curves demonstrated that an optimal cut-off value of RAR for predicting 90-days mortality was determined to be 5.453, yielding a sensitivity of 61.5% and specificity of 60.3%. Conclusion Elevated RAR (> 6.07) was associated with all-cause mortality at 90-days and 360-days among critically ill patients with rheumatic diseases, serving as an independent risk factor for unfavorable prognosis.
Collapse
Affiliation(s)
- Lijuan Yin
- Department of Rheumatology, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, Huzhou, Zhejiang, China
- Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou, China
- The Fifth School of Clinical Medicine, Zhejiang Chinese Medical University, Huzhou, China
| | - Jie Min
- Department of Intensive Care Unit, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, Huzhou, Zhejiang, China
- Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou, China
- The Fifth School of Clinical Medicine, Zhejiang Chinese Medical University, Huzhou, China
| | - Lei Zhong
- Department of Intensive Care Unit, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, Huzhou, Zhejiang, China
- Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou, China
- The Fifth School of Clinical Medicine, Zhejiang Chinese Medical University, Huzhou, China
| | - Qikai Shen
- Department of Intensive Care Unit, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, Huzhou, Zhejiang, China
- Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou, China
- The Fifth School of Clinical Medicine, Zhejiang Chinese Medical University, Huzhou, China
| |
Collapse
|
5
|
AYDIN K, TÜRK İ. The Diagnostic profile and clinical course of patients with rheumatic diseases in the medical intensive care unit. Turk J Med Sci 2023; 53:1084-1093. [PMID: 38813000 PMCID: PMC10763782 DOI: 10.55730/1300-0144.5673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 10/26/2023] [Accepted: 09/06/2023] [Indexed: 05/31/2024] Open
Abstract
Background/aim Immunosuppressive and immunomodulatory treatments developed in recent years as a result of a better understanding of the pathophysiology of systemic rheumatic diseases (SRDs) improve the prognosis. Despite medical advances, individuals with SRDs at any stage may require intensive care and have a high mortality rate. The aim of this study was to investigate the demographic and clinical characteristics of patients with rheumatic diseases admitted to the intensive care unit (ICU), and the factors associated with the risk of mortality. Materials and methods This was a retrospective, cross-sectional study that included patients with rheumatic diseases in the medical ICU. Factors of ICU 28-day mortality were identified by multiple-variable logistic analysis. Results A total of 127 patients with SRDs admitted to the medical ICU were enrolled. Systemic lupus erythematosus (SLE) (32.3%) was the most common diagnosis of SRDs in patients admitted to the ICU. The reasons for admission to the ICU were combined infection and primary SRD flare-up (35.4%), primary SRD flare-up (22%), SRD-unrelated reasons (22%), infection (17.3%), drug side effects (3.9%), and SRD-related complications (0.8%). The most common organ dysfunctions before (49.6%) and during (77.2%) admission to ICU were in the respiratory system. The 28-day mortality was 78 (61.4%). While the maximum procalcitonin, serum lactate, and blood urea nitrogen (BUN) levels were higher in the nonsurvivor group, the platelet and serum albumin levels were statistically significantly lower than those in the survivor group (p < 0.05). Acute respiratory failure (ARF), the presence of septic shock, the need for invasive mechanical ventilation (IMV), BUN level, and low platelet-lymphocyte ratio (PLR) were significant in the final multiple-variable model. Conclusion Significant predictors of mortality in patients with rheumatic diseases may include ARF, septic shock, the need for IMV, and high BUN and low PLR levels.
Collapse
Affiliation(s)
- Kaniye AYDIN
- Division of Medical Intensive Care Unit, Department of Internal Medicine, Faculty of Medicine, Çukurova University, Adana,
Turkiye
| | - İpek TÜRK
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Çukurova University, Adana,
Turkiye
| |
Collapse
|
6
|
Tocut M, Kolitz T, Shovman O, Haviv Y, Boaz M, Laviel S, Debi S, Nama M, Akria A, Shoenfeld Y, Soroksky A, Zandman-Goddard G. Outcomes of ICU patients treated with intravenous immunoglobulin for sepsis or autoimmune diseases. Clin Exp Rheumatol 2022; 21:103205. [PMID: 36195246 DOI: 10.1016/j.autrev.2022.103205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/28/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To evaluate the outcomes of hospitalized patients in two intensive care units (ICU) treated with intravenous immunoglobulin (IVIg) added to standard-of-care therapy. The indications for IVIg therapy were sepsis or autoimmune disease. METHODS We conducted a retrospective study involving adult patients with sepsis and autoimmune diseases, who received IVIg in the ICU at Wolfson and Sheba Medical Centers. A predefined chart was compiled on Excel to include a complete demographic collection, patient comorbidities, chronic medication use, disease severity scores (Charlson Comorbidity Index; SOFA and APACHE II index scores), indication and dosage of IVIg administration, duration of hospitalization and mortality rates. RESULTS Patients (n - 111) were divided into 2 groups: patients with sepsis only (n-67) and patients with autoimmune disease only (n-44). Septic patients had a shorter ICU stay, received IVIg early, and had reduced mortality if treated with high dose IVIg. Patients with autoimmune diseases did not have a favorable outcome despite IVIg treatment. In this group, IVIg was administered later than in the sepsis group. CONCLUSIONS IVIg therapy improved the outcomes for ICU patients with sepsis.
Collapse
Affiliation(s)
- Milena Tocut
- Department of Medicine C, Wolfson Medical Center, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel; The Center for Autoimmune Diseases
| | - Tamara Kolitz
- Sackler Faculty of Medicine, Tel-Aviv University, Israel; Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center
| | - Ora Shovman
- Sackler Faculty of Medicine, Tel-Aviv University, Israel; The Center for Autoimmune Diseases; Department of Medicine B
| | - Yael Haviv
- Sackler Faculty of Medicine, Tel-Aviv University, Israel; Intensive Care Unit, Sheba Medical Center, Israel
| | - Mona Boaz
- Nutrition Sciences Department, Ariel University, Israel
| | - Shira Laviel
- Department of Medicine C, Wolfson Medical Center, Israel
| | - Stav Debi
- Department of Medicine C, Wolfson Medical Center, Israel
| | - Mona Nama
- Department of Medicine C, Wolfson Medical Center, Israel
| | - Amir Akria
- Department of Medicine C, Wolfson Medical Center, Israel
| | - Yehuda Shoenfeld
- Sackler Faculty of Medicine, Tel-Aviv University, Israel; The Center for Autoimmune Diseases; Ariel University, Ariel, Israel; I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Arie Soroksky
- Sackler Faculty of Medicine, Tel-Aviv University, Israel; Intensive Care Unit, Wolfson Medical Center, Israel
| | - Gisele Zandman-Goddard
- Department of Medicine C, Wolfson Medical Center, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel.
| |
Collapse
|
7
|
Determination of the main causes, outcome, and prognostic factors of patients with rheumatologic diseases admitted to the medical intensive care unit in Southern Iran. Clin Rheumatol 2022; 41:3859-3868. [PMID: 35969279 PMCID: PMC9376566 DOI: 10.1007/s10067-022-06334-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Systemic rheumatic diseases (SRD) are a heterogeneous group of diseases that can involve several organ systems and occasionally requires intensive care unit (ICU) admission because of severe systemic disease, life-threatening organ involvement, or complication of treatment. The objective of this study is to determine the causes, outcome, and prognostic factors of patients with rheumatologic diseases admitted in teaching medical ICUs in southern Iran. METHODS A retrospective case review of all patients with rheumatologic diseases admitted in the academic medical ICUs in two referral hospitals in southern Iran, from March 2015 to January 2020. Patients' data were documented from their hospital records and the cause of admission, in-hospital outcome, and prognostic factors was evaluated. RESULTS Ninety-one patients were included, of which 71.4% were female. Systemic lupus erythematosus (54.9%) was the most common disease. Nineteen (20.9%) patients were new cases of rheumatological disease. The most frequent symptom for admittance was dyspnea (54.9%) and hemoptysis (20.9%). The in-hospital mortality rate was 48%, and the leading cause of death was infection (29 patients; 65.5%) followed by disease activity (18 patients; 40.9%). Also, the death of 29.5% of patients was presumed due to both disease activity and infection. Factors associated with mortality included renal insufficiency (p < 0.028), infection (p < 0.001), pneumonia (p < 0.042), dyspnea (p < 0.042), loss of consciousness (p < 0.046), azathioprine consumption (p < 0.004) during 1 month before ICU admission, mechanical ventilation (p < 0.001), renal replacement therapy (p < 0.001), CNS involvement (p < 0.009), and ICU medications such as cyclosporine and azathioprine (0.03 and 0.03, respectively) or treatments such as plasmapheresis (p < 0.018). CONCLUSION The ICU mortality rate of patients with SRD was high. Infection and disease exacerbation are the leading reasons for ICU admission in systemic rheumatic diseases. Intensivists must keep in mind that SRD exacerbation may require immunosuppressive agents along with lifesaving interventions, more particularly in newly diagnosed SRDs. Key Points • The ICU mortality rate of patients with SRD was high. • Infection and disease exacerbation are the leading reasons for ICU admission in systemic rheumatic diseases. • 63.8% of our patients fall into this category of new cases of rheumatologic disease and disease flare-up.
Collapse
|
8
|
Shi Y, Peng JM, Qin HY, Du B. Metagenomic next-generation sequencing: A promising tool for diagnosis and treatment of suspected pneumonia in rheumatic patients with acute respiratory failure: Retrospective cohort study. Front Cell Infect Microbiol 2022; 12:941930. [PMID: 35992169 PMCID: PMC9381725 DOI: 10.3389/fcimb.2022.941930] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022] Open
Abstract
Background The effectiveness of metagenomic next-generation sequencing (mNGS) in respiratory pathogen detection and clinical decision-making in critically rheumatic patients remains largely unexplored. Methods A single-center retrospective study of 58 rheumatic patients who were admitted to ICU due to suspected pneumonia with acute respiratory failure if they underwent both bronchoalveolar lavage fluid specimen mNGS and combined microbiological tests (CMTs) was conducted to compare their diagnostic performance, using clinical composite diagnosis as the gold standard. Treatment modifications based on mNGS results were also reviewed. Results Forty-three patients were diagnosed with microbiologically confirmed pneumonia and 15 were considered as a non-infectious disease. mNGS outperformed CMTs in the accurate diagnosis of infectious and non-infectious lung infiltration (98.1% [57/58] vs. 87.9% [51/58], P = 0.031). A total of 94 causative pathogens were defined by the gold standard and 27 patients had polymicrobial pneumonia. The sensitivity of pathogen detection and complete concordance with the gold standard by mNGS exceeded those by CMTs (92.6% [87/94] vs. 76.6% [72/94], P < 0.001 and 72.1% [31/43] vs. 51.2% [22/43], P = 0.004, respectively). Moreover, 22 pathogens were detected only by mNGS and confirmed by orthogonal test. Accordingly, the etiological diagnosis changed in 19 cases, and the empirical treatment improved in 14 cases, including 8 cases of rescue treatment and 11 of antibiotics de-escalation. At the pathogen-type level, both methods were comparable for bacteria, but mNGS was advantageous to identify viruses (accuracy: 100% vs. 81%, P = 0.004). For Pneumocystis jirovecii detection, mNGS improved the sensitivity compared with Gomori’s methenamine silver stain (91.7% vs. 4.2%, P < 0.001) and was higher than polymerase chain reaction (79.2%), but the difference was not significant (P = 0.289). In terms of Aspergillus, the better sensitivity with a combination of culture and galactomannan test than that with mNGS was found (100% vs. 66.7%, P = 0.033). Conclusions mNGS has an excellent accuracy in etiological diagnosis and pathogen detection of suspected pneumonia in critically rheumatic patients, which has potential significance for clinical decision-making. Its superiority to different types of pathogens depends on the comprehensiveness of CMTs.
Collapse
|
9
|
Assan F, Bay P, Mathian A, Hekimian G, Bréchot N, Quentric P, Moyon Q, Schmidt M, Cohen-Aubart F, Haroche J, Amoura Z, Luyt CE, Combes A, Pineton de Chambrun M. In-ICU-acquired infections in flare-up systemic rheumatic disease patients receiving immunosuppressant. Clin Rheumatol 2022; 41:2845-2854. [PMID: 35534696 DOI: 10.1007/s10067-022-06197-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/25/2022] [Accepted: 04/30/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Systemic rheumatic diseases (SRDs) are a group of inflammatory disorders that can need intensive care unit (ICU) admission during a flare-up, requiring administration of immunosuppressants. We undertook this study to determine the frequency, outcome, and occurrence associated factors of infections in flare-up SRD patients receiving immunosuppressant. METHODS Monocenter, a retrospective study including SRD patients admitted to ICU for a flare-up requiring immunosuppressant from 2004 to 2019. The primary endpoint was in-ICU-acquired infections. RESULTS Ninety-eight patients (female/male ratio: 1.6; mean age at admission: 39.5 ± 17.4 years) were admitted to the ICU for a SRD flare-up, inaugural in 61.2% cases. A specific treatment was given to every patient: corticosteroids 100%, cyclophosphamide 45.9%, plasma exchange 46.9%. Ninety-five infections occurred in 35 (36%) patients mainly pneumonias. The overall in-hospital mortality was 17.3%, and 46% of patients with a nosocomial infection died during their ICU stay. The logistic regression multivariable model retained renal replacement therapy and mechanical ventilation as independent predictors of infection. CONCLUSION In-ICU-acquired infection in SRD flare-up is a frequent event associated with organ failures but not with in-ICU use of immunosuppressants. These data suggest that the fear of infection should not withhold a careful in-ICU use of immunosuppressive drugs. Key Points • In-ICU infections are frequent in flare-up systemic rheumatic disease patients. • Infections are associated with increased mortality. • Cyclophosphamide given in ICU was not independently associated with infection. • Severe neutropenia occurred in 27% of patients receiving cyclophosphamide in ICU.
Collapse
Affiliation(s)
- Florence Assan
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Pierre Bay
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France
| | - Alexis Mathian
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Guillaume Hekimian
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France
| | - Nicolas Bréchot
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France
| | - Paul Quentric
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France.,Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Inserm, Paris, France
| | - Quentin Moyon
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France.,Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France
| | - Matthieu Schmidt
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France.,INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, F-75013, Paris, France
| | - Fleur Cohen-Aubart
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Julien Haroche
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Zahir Amoura
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France.,INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, F-75013, Paris, France
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France.,INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, F-75013, Paris, France
| | - Marc Pineton de Chambrun
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France. .,Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France. .,Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Inserm, Paris, France. .,INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, F-75013, Paris, France.
| |
Collapse
|
10
|
Kouchit Y, Morand L, Martis N. Mortality and its risk factors in critically ill patients with connective tissue diseases: A meta-analysis. Eur J Intern Med 2022; 98:83-92. [PMID: 35151541 DOI: 10.1016/j.ejim.2022.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/16/2022] [Accepted: 02/01/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Systemic lupus erythematosus (SLE), primary Sjögren's syndrome (pSS), systemic sclerosis (SSc), idiopathic inflammatory myopathies (IIM) and rheumatoid arthritis (RA) are connective tissue diseases (CTD) whose complications can lead to management in the intensive care unit (ICU). OBJECTIVES To estimate by meta-analysis ICU mortality rates for CTD. METHODS A systematic literature review was performed to identify articles studying critically ill CTD patients. A random-effects model was chosen for analysis. Pooled proportion mortality was calculated using aggregated-data meta-analysis with a random-effects model and assessment of heterogeneity with the I2 statistic. Risk of bias was assessed using the quality assessment tool. RESULTS Of the 5694 individual publications, a sample of 31 independent cohorts was used for the meta-analysis totalling 5007 patients. The main cause for admission was sepsis (43%) followed by "flare-ups" (40%). The overall pooled proportion of mortality of CTD patients across all 31 studies was 33% (95%CI: 28-38%). In the IIM subgroup and that of SSc, mortality was 70% (95%CI: 46-86%) and 40% (95%CI: 25-47%), respectively. In the SLE subgroup, mortality was similar to the overall pooled mortality of 35% (95%CI: 29-42%). Subgroup mortality for RA and pSS patients was respectively 20% (95%CI: 11-33%) and 17% (95%CI: 6-41%); lower than the overall pooled mortality. Heterogeneity in each subgroup remained high. CONCLUSION The overall pooled proportion of mortality of ICU patients with CTD was 33% (95%CI: 28-38%), with a high heterogeneity (I2= 89%). In the subgroup analysis, mortality was higher for patients with IIM and SSc.
Collapse
Affiliation(s)
- Yanis Kouchit
- Department of Internal Medicine and Clinical Immunology, University Hospital of Nice, Archet Hospital, 151 route de Saint-Antoine de Ginestière, 06200, Nice, France; Côte d'Azur University, Medical School of Nice, 28 avenue de Valombrose, 06107, Nice, France
| | - Lucas Morand
- Côte d'Azur University, Medical School of Nice, 28 avenue de Valombrose, 06107, Nice, France; Department of Medical Intensive Care, University Hospital of Nice, Archet Hospital, 151 route de Saint-Antoine de Ginestière, 06200, Nice, France
| | - Nihal Martis
- Department of Internal Medicine and Clinical Immunology, University Hospital of Nice, Archet Hospital, 151 route de Saint-Antoine de Ginestière, 06200, Nice, France; Côte d'Azur University, Medical School of Nice, 28 avenue de Valombrose, 06107, Nice, France.
| |
Collapse
|
11
|
Zhang Y, Guo J, Zhang P, Zhang L, Duan X, Shi X, Guo N, Liu S. Predictors of Mortality in Critically Ill Patients With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Front Med (Lausanne) 2021; 8:762004. [PMID: 34760903 PMCID: PMC8573203 DOI: 10.3389/fmed.2021.762004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 09/28/2021] [Indexed: 01/29/2023] Open
Abstract
Background: Patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV) may require intensive care unit (ICU) admission due to different reasons, and the in-ICU mortality is high among AAV patients. The aim of this study was to explore the clinical features and risk factors of mortality of patients with AAV in the ICU. Methods: A retrospective study was conducted based on 83 AAV patients admitted to the ICU in a tertiary medical institution in China. Data on clinical characteristics, laboratory tests, treatment in ICU and outcomes were collected. The data were analyzed using univariate and multivariate logistic regression analysis to explore the variables that were independently related to mortality. Kaplan–Meier method was used to assess the long-term survival. Results: Among the 83 patients, 41 (49.4%) were female. The mean age of patients was 66 ± 13 years. Forty-four patients deceased, with the in-ICU mortality of 53%. The most common cause for ICU admission was active vasculitis (40/83, 48.2%). The main cause of death was infection (27/44, 61.4%) followed by active vasculitis (15/44, 34.1%). A multivariate analysis revealed that the Acute Physiology and Chronic Health Evaluation II (APACHE II) at ICU admission (OR = 1.333, 95% CI: 1.031–1.722) and respiratory failure (OR = 620.452, 95% CI: 11.495–33490.306) were independent risk factors of in-ICU death. However, hemoglobin (OR = 0.919, 95% CI: 0.849–0.995) was an independent protective factor. The nomogram established in this study was practical in predicting the risk of in-ICU mortality for AAV patients. Moreover, for 39 patients survived to the ICU stay, the cumulative survival rates at 0.5, 1, and 5 years were 58.3%, 54.2%, and 33.9%, respectively, and the median survival time was 14 months. Conclusion: In our study, active vasculitis was the most frequent reason for ICU admission, and the main cause of death was infection. APACHE II and respiratory failure were independent risk factors while hemoglobin was an independent protective factor of in-ICU mortality for AAV patients admitted to the ICU. The risk prediction model developed in this study may be a useful tool for clinicians in early recognition of high-risk patients and applying appropriate management.
Collapse
Affiliation(s)
- Yuqi Zhang
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jinyan Guo
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Panpan Zhang
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lei Zhang
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaoguang Duan
- Department of Intensive Care Unit, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaofei Shi
- Department of Rheumatology, the First Affiliated Hospital and College of Clinical Medicine, Henan University of Science and Technology, Luoyang, China
| | - Nailiang Guo
- Department of Rheumatology and Immunology, Xinyang Central Hospital, Xinyang, China
| | - Shengyun Liu
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| |
Collapse
|
12
|
Parperis K, Al-Charakh M, Nzuonkwelle S, McPherson M, Al-Marzooq A, Bhattarai B. Characteristics and Outcomes Among Patients With Autoimmune Rheumatic Diseases Requiring a Higher Level of Care. J Clin Rheumatol 2021; 27:286-291. [PMID: 32053541 DOI: 10.1097/rhu.0000000000001321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Patients with autoimmune rheumatic diseases (ARDs) have a higher risk of developing organ failure, and they may require admission to the intensive care unit (ICU). The aim of our study is to determine the reasons for admission to the ICU, identify potential risk factors associated with mortality, and assess the outcomes of patients with ARD diseases admitted to the ICU. METHODS We conducted a medical records review study of patients with ARD admitted to the ICU from 2012 to 2018. Patient data included demographic and clinical characteristics, ICU admission diagnoses, length of stay, complications, and immunosuppressive regimen. Short-term and long-term outcomes were assessed. RESULTS A total of 80 ARD patients were identified with the mean age of 48.8, 67% were female, and 56% were Hispanic. The most common disease associated with ICU admission was systemic lupus erythematosus (42%), followed by rheumatoid arthritis (26%), and 12% of patients had systemic vasculitis. Sepsis was the leading cause of ICU admission, accounting for 31%, followed by respiratory failure due to pneumonia (10%) and congestive heart failure (10%). Twenty percent of patients died in the ICU, 5% died 30 days after ICU admission, and 7.5% died within 1 year after the ICU stay, resulting in overall mortality of 33% by the end of 1 year. Nonsurvivors were more likely to need mechanical ventilation (p = 0.001), vasopressor support (p < 0.001), had renal (p = 0.041) or cardiovascular (p < 0.001) involvement on admission, APACHE II score higher than 19 (p = 0.001), and 4 days or longer stay in the ICU (p = 0.001). CONCLUSIONS Our findings indicated that systemic lupus erythematosus is the most common ARD associated with ICU admission, and sepsis was the most frequent cause. Predictors associated with higher mortality were the requirement for mechanical ventilation, vasopressor support, increase length of ICU stay, and renal and cardiovascular involvement on admission.
Collapse
Affiliation(s)
| | | | | | - Mark McPherson
- Department of Medicine, Maricopa Integrated Health System
| | - Ali Al-Marzooq
- Department of Medicine, Maricopa Integrated Health System
| | | |
Collapse
|
13
|
Chabert P, Danjou W, Mezidi M, Berthiller J, Bestion A, Fred AA, Guerin C, Argaud L, Piriou V, Bonnefoy-Cudraz E, Lehot JJ, Fellahi JL, Rimmele T, Aubrun F, Richard JC, Gallay L, Hot A. Short- and long-term prognosis of acute critically ill patients with systemic rheumatic diseases: A retrospective multicentre study. Medicine (Baltimore) 2021; 100:e26164. [PMID: 34477112 PMCID: PMC8415942 DOI: 10.1097/md.0000000000026164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 05/06/2021] [Indexed: 01/05/2023] Open
Abstract
Patients with systemic rheumatic disease (SRD) share the risks of multi-organ flare-up, cardiovascular diseases, and immunosuppression. Such situations can lead to an acute critical illness. The present study describes the clinical features of SRD patients admitted to the intensive care unit (ICU) and their short- and long- term mortality.We performed a multicentre retrospective study in 10 French ICU in Lyon, France. Inclusion criteria were SRD diagnosis and admission for an acute organ failure. The primary endpoint was ICU mortality.A total of 271 patients were included. SRD included systemic lupus erythematosus (23.2% of included patients), vasculitis (10.7%), systemic sclerosis (10.7%), idiopathic inflammatory myopathy (6.3%), and other connective tissue disorders (rheumatoid arthritis, Sjögren and Sharp syndromes; 50.9%). Initial organ failure(s) were shock (43.5% of included patients), acute kidney injury (30.5%), and acute respiratory failure (23.2%). The cause(s) of ICU admission included sepsis (61.6%), cardiovascular events (33.9%), SRD-flare up (32.8%), and decompensations related to comorbidities (28%). The ICU mortality reached 14.3%. The factors associated with ICU mortality were chronic cardiac failure, invasive ventilation and admission in ICU for another reason than sepsis or SRD flare-up. The median follow-up after ICU discharge was 33.6 months. During follow-up, 109 patients died. The factors associated with long-term mortality included age, Charlson comorbidity index, and ICU admission for sepsis or SRD flare-up.The ICU mortality of patients with SRD was low. Sepsis was the first cause of admission. Cardiovascular events and comorbidities negatively impacted ICU mortality. Admission for sepsis or SRD flare-up exerted a negative effect on the long-term outcome.
Collapse
Affiliation(s)
- Paul Chabert
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital de la Croix Rousse, Lyon, France
| | - William Danjou
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital de la Croix Rousse, Lyon, France
| | - Mehdi Mezidi
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital de la Croix Rousse, Lyon, France
| | | | - Audrey Bestion
- Hospices Civils de Lyon, Département Information Médicale, France
| | - Abla-Akpene Fred
- Hospices Civils de Lyon, Département Information Médicale, France
| | - Claude Guerin
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital de la Croix Rousse, Lyon, France
- Université de Lyon, France
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital Edouard Herriot, Lyon, France
- Institut Mondor de Recherche Biomédicale INSERM 955, ERL CNRS, 7000 Créteil, France
| | - Laurent Argaud
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital Edouard Herriot, Lyon, France
| | - Vincent Piriou
- Université de Lyon, France
- Hospices Civils de Lyon, Anesthésie-Réanimation-Médecine Intensive, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Eric Bonnefoy-Cudraz
- Hospices Civils de Lyon, Service d’urgences cardiologiques et de soins intensifs de cardiologie, Hôpital Louis Pradel, Bron, France
| | - Jean-Jacques Lehot
- Hospices Civils de Lyon, Anesthésie-Réanimation Neurologique, Hôpital Pierre Wertheimer, Bron, France
| | - Jean-Luc Fellahi
- Hospices Civils de Lyon, Anesthésie-Réanimation cardio-thoracique et vasculaire, Hôpital Louis Pradel, Bron, France
| | - Thomas Rimmele
- Hospices Civils de Lyon, Anesthésie-Réanimation, Hôpital Edouard Herriot, Lyon, France
| | - Frederic Aubrun
- Hospices Civils de Lyon, Anesthésie-Réanimation, Hôpital de la croix rousse, Lyon, France
| | - Jean-Christophe Richard
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital de la Croix Rousse, Lyon, France
- Université de Lyon, France
| | - Laure Gallay
- Université de Lyon, France
- Hospices Civils de Lyon, Médecine Interne, Hôpital Edouard Herriot, Lyon, France
| | - Arnaud Hot
- Université de Lyon, France
- Hospices Civils de Lyon, Médecine Interne, Hôpital Edouard Herriot, Lyon, France
| |
Collapse
|
14
|
Raibagkar P, Ramineni A. Autoimmune Neurologic Emergencies. Neurol Clin 2021; 39:589-614. [PMID: 33896534 DOI: 10.1016/j.ncl.2021.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Over the past decade, understanding of autoimmune neurologic disorders has exponentially increased. Many patients present as a neurologic emergency and require timely evaluation with rapid management and intensive care. However, the diagnosis is often either missed or delayed, which may lead to a significant burden of disabling morbidity and even mortality. A high level of suspicion in the at-risk population should be maintained to facilitate more rapid diagnosis and prompt treatment. At present, there is no all-encompassing algorithm specifically applicable to the management of fulminant autoimmune neurologic disorders. This article discusses manifestations and management of various autoimmune neurologic emergencies.
Collapse
Affiliation(s)
- Pooja Raibagkar
- Concord Hospital Neurology Associates, 246 Pleasant Street, Concord, NH 03301, USA.
| | - Anil Ramineni
- Lahey Hospital & Medical Center, Beth Israel Lahey Health, 41 Mall Road, Burlington, MA 01803, USA
| |
Collapse
|
15
|
Banuls L, Vanoverschelde J, Garnier F, Amalric M, Jaber S, Charbit J, Chalard K, Mourad M, Benchabane N, Benomar R, Besnard N, Daubin D, Brunot V, Klouche K, Larcher R. Interstitial Lung Disease Worsens Short- and Long-Term Outcomes of Systemic Rheumatic Disease Patients Admitted to the ICU: A Multicenter Study. J Clin Med 2021; 10:jcm10051037. [PMID: 33802364 PMCID: PMC7959321 DOI: 10.3390/jcm10051037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 11/16/2022] Open
Abstract
Critically ill patients with systemic rheumatic diseases (SRDs) have a fair prognosis, while those with interstitial lung disease (ILD) have a poorer outcome. However, the prognosis of SRD patients with ILD admitted to the intensive care unit (ICU) remains unclear. We conducted a case–control study to investigate the outcomes of critically ill SRD-ILD patients. Consecutive SRD-ILD patients admitted to five ICUs from January 2007 to December 2017 were compared to SRD patients without ILD. Mortality rates were compared between groups, and prognostic factors were then identified. One hundred and forty critically ill SRD patients were included in the study. Among the 70 patients with SRD–ILD, the SRDs were connective tissue diseases (56%), vasculitis (29%), sarcoidosis (13%), and spondylarthritis (3%). Patients were mainly admitted for acute exacerbation of SRD-ILD (36%) or infection (34%). ICU, in-hospital, and one-year mortality rates in SRD-ILD patients were higher than in SRD patients without ILD (n = 70): 40% vs. 16% (p < 0.01), 49% vs. 19% (p < 0.01), and 66% vs. 40% (p < 0.01), respectively. Hypoxemia, high sequential organ failure assessment (SOFA) score, and admission for ILD acute exacerbation were associated with ICU mortality. In conclusion, ILD worsened the outcomes of SRD patients admitted to the ICU. Admissions related to SRD-ILD acute exacerbation and the severity of the acute respiratory failure were associated with ICU mortality.
Collapse
Affiliation(s)
- Lorrain Banuls
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier University Hospital, 191, avenue du Doyen Gaston Giraud, 34090 Montpellier, France; (L.B.); (F.G.); (M.A.); (N.B.); (R.B.); (N.B.); (D.D.); (V.B.); (K.K.)
| | - Juliette Vanoverschelde
- Radiology Department, Arnaud de Villeneuve Hospital, Montpellier University Hospital, 34090 Montpellier, France;
| | - Fanny Garnier
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier University Hospital, 191, avenue du Doyen Gaston Giraud, 34090 Montpellier, France; (L.B.); (F.G.); (M.A.); (N.B.); (R.B.); (N.B.); (D.D.); (V.B.); (K.K.)
| | - Matthieu Amalric
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier University Hospital, 191, avenue du Doyen Gaston Giraud, 34090 Montpellier, France; (L.B.); (F.G.); (M.A.); (N.B.); (R.B.); (N.B.); (D.D.); (V.B.); (K.K.)
| | - Samir Jaber
- Department of Anesthesiology and Critical Care, Saint Eloi Hospital, Montpellier University Hospital, 34090 Montpellier, France;
- PhyMedExp, University of Montpellier, INSERM (French Institut of Health and Medical Research), CNRS (French National Centre for Scientific Research), 34090 Montpellier, France;
| | - Jonathan Charbit
- Department of Anesthesiology and Critical Care, Lapeyronie Hospital, Montpellier University Hospital, 34090 Montpellier, France;
| | - Kevin Chalard
- Department of Anesthesiology and Critical Care, Gui de Chauliac Hospital, Montpellier University Hospital, 34090 Montpellier, France;
| | - Marc Mourad
- PhyMedExp, University of Montpellier, INSERM (French Institut of Health and Medical Research), CNRS (French National Centre for Scientific Research), 34090 Montpellier, France;
- Department of Anesthesiology and Critical Care, Arnaud de Villeneuve Hospital, Montpellier University Hospital, 34090 Montpellier, France
| | - Nacim Benchabane
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier University Hospital, 191, avenue du Doyen Gaston Giraud, 34090 Montpellier, France; (L.B.); (F.G.); (M.A.); (N.B.); (R.B.); (N.B.); (D.D.); (V.B.); (K.K.)
- PhyMedExp, University of Montpellier, INSERM (French Institut of Health and Medical Research), CNRS (French National Centre for Scientific Research), 34090 Montpellier, France;
| | - Racim Benomar
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier University Hospital, 191, avenue du Doyen Gaston Giraud, 34090 Montpellier, France; (L.B.); (F.G.); (M.A.); (N.B.); (R.B.); (N.B.); (D.D.); (V.B.); (K.K.)
| | - Noemie Besnard
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier University Hospital, 191, avenue du Doyen Gaston Giraud, 34090 Montpellier, France; (L.B.); (F.G.); (M.A.); (N.B.); (R.B.); (N.B.); (D.D.); (V.B.); (K.K.)
| | - Delphine Daubin
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier University Hospital, 191, avenue du Doyen Gaston Giraud, 34090 Montpellier, France; (L.B.); (F.G.); (M.A.); (N.B.); (R.B.); (N.B.); (D.D.); (V.B.); (K.K.)
| | - Vincent Brunot
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier University Hospital, 191, avenue du Doyen Gaston Giraud, 34090 Montpellier, France; (L.B.); (F.G.); (M.A.); (N.B.); (R.B.); (N.B.); (D.D.); (V.B.); (K.K.)
| | - Kada Klouche
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier University Hospital, 191, avenue du Doyen Gaston Giraud, 34090 Montpellier, France; (L.B.); (F.G.); (M.A.); (N.B.); (R.B.); (N.B.); (D.D.); (V.B.); (K.K.)
- PhyMedExp, University of Montpellier, INSERM (French Institut of Health and Medical Research), CNRS (French National Centre for Scientific Research), 34090 Montpellier, France;
| | - Romaric Larcher
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier University Hospital, 191, avenue du Doyen Gaston Giraud, 34090 Montpellier, France; (L.B.); (F.G.); (M.A.); (N.B.); (R.B.); (N.B.); (D.D.); (V.B.); (K.K.)
- PhyMedExp, University of Montpellier, INSERM (French Institut of Health and Medical Research), CNRS (French National Centre for Scientific Research), 34090 Montpellier, France;
- Correspondence:
| |
Collapse
|
16
|
Arleo T, Tong D, Shabto J, O'Keefe G, Khosroshahi A. Clinical course and outcomes of COVID-19 in rheumatic disease patients: a case cohort study with a diverse population. Clin Rheumatol 2021; 40:2633-2642. [PMID: 33420870 PMCID: PMC7794618 DOI: 10.1007/s10067-021-05578-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 12/28/2020] [Accepted: 01/01/2021] [Indexed: 02/06/2023]
Abstract
Objective To determine clinical course and outcomes in rheumatic disease patients with coronavirus disease 2019 (COVID-19) and compare results to uninfected patients. Methods We conducted a case cohort study of autoimmune disease patients with COVID-19 (confirmed by severe acute respiratory syndrome coronavirus 2 PCR) from February 1, 2020, to July 31, 2020, and compared them in a 1:3 ratio with uninfected patients who were matched based on race, age, sex, and comorbidity index. Patient demographics, clinical course, and outcomes were compared among these patient groups. Results A total of 70 rheumatic disease patients with COVID-19 (mean age, 56.6 years; 64% African American) were identified. The 34 (49%) patients who were hospitalized used oral glucocorticoids more frequently than those treated as outpatients (p < 0.01). All 10 patients using anti-TNFα medications were treated as outpatients (p < 0.01). Those hospitalized with COVID-19 more often required ICU admission (17 (50%) vs 27 (26%), p = 0.01) and intubation (10 (29%) vs 6 (6%), p < 0.01) than uninfected patients and had higher mortality rates (6 (18%) vs 3 (3%), p < 0.01). Of the six COVID-19 patients who died, only one was of African ancestry (p = 0.03). Conclusion Rheumatic disease patients infected with COVID-19 were more likely to require ICU admission, ventilation, and died more frequently versus uninfected patients with autoimmune disease. Patients on anti-TNFα medications were hospitalized less frequently, while those on chronic glucocorticoids were hospitalized more frequently. These findings have important implications for medication choice in rheumatic disease patients during the ongoing spread of COVID-19.Key Points • We show that hospitalized rheumatic disease patients with COVID-19 have poorer outcomes including ICU admission, ventilation, and death compared to hospitalized rheumatic disease patients not infected with COVID-19. • This study adds further support regarding protective effects of anti-TNFα medications in COVID-19 disease course, with 0 of 10 of these patients required hospitalization. |
Supplementary Information The online version contains supplementary material available at 10.1007/s10067-021-05578-x.
Collapse
Affiliation(s)
- Timothy Arleo
- Emory University School of Medicine, Atlanta, GA, USA
| | - David Tong
- Division of Hospital Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Julie Shabto
- Emory University School of Medicine, Atlanta, GA, USA
| | - Ghazala O'Keefe
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA
| | - Arezou Khosroshahi
- Division of Rheumatology, Emory University School of Medicine, 244 Whitehead Bldg., 615 Michael Street, Atlanta, GA, 30322, USA.
| |
Collapse
|
17
|
Fujiwara T, Tokuda K, Momii K, Shiomoto K, Tsushima H, Akasaki Y, Ikemura S, Fukushi JI, Maki J, Kaku N, Akahoshi T, Taguchi T, Nakashima Y. Prognostic factors for the short-term mortality of patients with rheumatoid arthritis admitted to intensive care units. BMC Rheumatol 2020; 4:64. [PMID: 33292831 PMCID: PMC7716508 DOI: 10.1186/s41927-020-00164-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 08/30/2020] [Indexed: 12/12/2022] Open
Abstract
Background Patients with rheumatoid arthritis (RA) have high mortality risk and are frequently treated in intensive care units (ICUs). Methods This was a retrospective observational study. This study included 67 patients (20 males, 47 females) with RA who were admitted at the ICU of our institution for ≥48 h between January 2008 and December 2017. We analyzed the 30-day mortality of these patients and the investigated prognostic factors in RA patients admitted to our ICU. Results Upon admission, the median age was 70 (range, 33–96) years, and RA duration was 10 (range, 0–61) years. The 5-year survival after ICU admission was 47%, and 30-day, 90-day, and 1-year mortality rates were 22, 27, and 37%, respectively. The major reasons for ICU admission were cardiovascular complications (24%) and infection (40%) and the most common ICU treatments were mechanical ventilation (69%), renal replacement (25%), and vasopressor (78%). In the 30-day mortality group, infection led to a fatal outcome in most cases (67%), and nonsurvival was associated with a significantly higher glucocorticoid dose, updated Charlson’s comorbidity index (CCI), and acute physiology and chronic health evaluation (APACHE) II score. Laboratory data obtained at ICU admission showed that lower platelet number and total protein and higher creatinine and prothrombin time international normalized ratio (PT-INR) indicated significantly poorer prognosis. The multivariate Cox proportional hazard model revealed that nonuse of csDMARDs, high updated CCI, increased APACHE II score, and prolonged PT-INR were associated with a higher risk of mortality after ICU admission. Conclusion Our study demonstrated that the nonuse of csDMARDs, high updated CCI, elevated APACHE II score, and coagulation abnormalities predicted poorer prognosis in RA patients admitted to the ICU.
Collapse
Affiliation(s)
- Toshifumi Fujiwara
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka prefecture, 812-8582, Japan. .,Emergency & Critical Care Center, Kyushu University Hospital, Fukuoka-shi, Japan.
| | - Kentaro Tokuda
- Intensive Care Unit, Kyushu University Hospital, Fukuoka-shi, Japan
| | - Kenta Momii
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka prefecture, 812-8582, Japan.,Emergency & Critical Care Center, Kyushu University Hospital, Fukuoka-shi, Japan
| | - Kyohei Shiomoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka prefecture, 812-8582, Japan
| | - Hidetoshi Tsushima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka prefecture, 812-8582, Japan
| | - Yukio Akasaki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka prefecture, 812-8582, Japan
| | - Satoshi Ikemura
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka prefecture, 812-8582, Japan
| | - Jun-Ichi Fukushi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka prefecture, 812-8582, Japan
| | - Jun Maki
- Intensive Care Unit, Kyushu University Hospital, Fukuoka-shi, Japan
| | - Noriyuki Kaku
- Emergency & Critical Care Center, Kyushu University Hospital, Fukuoka-shi, Japan
| | - Tomohiko Akahoshi
- Emergency & Critical Care Center, Kyushu University Hospital, Fukuoka-shi, Japan
| | - Tomoaki Taguchi
- Emergency & Critical Care Center, Kyushu University Hospital, Fukuoka-shi, Japan.,Intensive Care Unit, Kyushu University Hospital, Fukuoka-shi, Japan
| | - Yasuharu Nakashima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka prefecture, 812-8582, Japan
| |
Collapse
|
18
|
Özdemir U, Ortaç Ersoy E, Yüksel RC, Kaya E, Aygencel G, Türkoğlu M, Topeli A, Güven M, Sungur M, Altintaş ND. Value of prognostic scores in antineutrophil cytoplasmic antibody (ANCA) associated vasculitis patients in intensive care unit: a multicenter retrospective cohort study from Turkey. Turk J Med Sci 2020; 50:1223-1230. [PMID: 32304194 PMCID: PMC7491289 DOI: 10.3906/sag-1911-86] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 04/18/2020] [Indexed: 11/11/2022] Open
Abstract
Background/aim There is a need for a scoring system for predicting ICU prognosis of patients with ANCA-associated vasculitis (AAV), but there are limited data on it in the literature. Therefore, we aimed to determine the scores that can estimate the prognosis of patients with AAV during intensive care follow up. Materials and methods All adult patients admitted to the medical ICUs of 4 reference university hospitals in Turkey due to AAV activation and/or disease/treatment complications in the last 10 years were included in this study. Demographic data, treatments before ICU, the Birmingham Vasculitis Activity Score (BVAS) score at the time of vasculitis diagnosis, and BVAS, APACHE II, SOFA, and SAPS II scores at the ICU admission, treatments, procedures, and complications during ICU stay were recorded for all AAV patients. Results Thirty-four patients were included in the study. The median age of the patients was 60 (42–70) years, and 64.7% were male. Twenty-five patients were diagnosed with Granulomatosis with polyangiitis, and 9 were diagnosed with Microscopic polyangiitis. The most common ICU admission causes were hemorrhage (85.3%) and sepsis/septic shock (67.6%). Twenty patients (58.8%) died in the ICU follow up. There were significant differences in APACHE II (P = 0.004) and SAPS II (P = 0.044) scores between survivors and nonsurvivors, while there were no significant differences in BVAS (during diagnosis P = 0.089 and ICU admission P = 0.539) and SOFA (P = 0.097) scores. APACHE II score was found to be an independent risk factor for ICU mortality (OR = 1.231, CI 95% = 1.011–1.498, P = 0.038) according to logistic regression analysis. An APACHE II score of greater than 20.5 predicted ICU mortality with 80% sensitivity and 70% specificity (AUC = 0.8, P = 0.004, Likelihood ratio = 2.6) according to the ROC curve analysis. Conclusion APACHE II score can be used for the prediction of ICU mortality in AAV patients.
Collapse
Affiliation(s)
- Uğur Özdemir
- Division of Intensive Care Medicine, Department of Internal Medicine, Gazi University School of Medicine, Ankara, Turkey
| | - Ebru Ortaç Ersoy
- Division of Intensive Care Medicine, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Recep Civan Yüksel
- Division of Intensive Care Medicine, Department of Internal Medicine, Erciyes University School of Medicine, Kayseri, Turkey
| | - Erhan Kaya
- Division of Intensive Care Medicine, Department of Internal Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Gülbin Aygencel
- Division of Intensive Care Medicine, Department of Internal Medicine, Gazi University School of Medicine, Ankara, Turkey
| | - Melda Türkoğlu
- Division of Intensive Care Medicine, Department of Internal Medicine, Gazi University School of Medicine, Ankara, Turkey
| | - Arzu Topeli
- Division of Intensive Care Medicine, Department of Internal Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Muhammet Güven
- Division of Intensive Care Medicine, Department of Internal Medicine, Erciyes University School of Medicine, Kayseri, Turkey
| | - Murat Sungur
- Division of Intensive Care Medicine, Department of Internal Medicine, Erciyes University School of Medicine, Kayseri, Turkey
| | - Neriman Defne Altintaş
- Division of Intensive Care Medicine, Department of Internal Medicine, Ankara University School of Medicine, Ankara, Turkey
| |
Collapse
|
19
|
Suárez-Avellaneda A, Quintana JH, Aragón CC, Gallego LM, Gallego CN, Bolaños JD, A Guerra M, Ochoa ME, Granados M, Ruiz-Ordoñez I, Tobón GJ. Systemic lupus erythematosus in the intensive care unit: a systematic review. Lupus 2020; 29:1364-1376. [PMID: 32723062 DOI: 10.1177/0961203320941941] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease with heterogeneous pathophysiologic mechanisms and diverse clinical manifestations. SLE is a frequent cause of intensive care unit (ICU) admissions. Multiple studies with controversial findings on the causes, evolution and outcomes of ICU-admitted patients with SLE have been published. The aim of this paper is to review the literature reporting the clinical characteristics and outcomes, such as mortality and associated factors, in such patients. Among the main causes of ICU admissions are SLE disease activity, respiratory failure, multi-organ failure and infections. The main factors associated with mortality are a high Acute Physiology and Chronic Health Evaluation (APACHE) score, the need for mechanical ventilation, and vasoactive and inotropic agent use. Reported mortality rates are 18.4%-78.5%. Therefore, it is important to evaluate SLE disease severity for optimizing clinical management and patient outcomes.
Collapse
Affiliation(s)
- Ana Suárez-Avellaneda
- GIRAT: Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional; Fundación Valle Del Lili and Universidad Icesi, Cali, Colombia
| | | | - Cristian C Aragón
- GIRAT: Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional; Fundación Valle Del Lili and Universidad Icesi, Cali, Colombia
| | | | | | | | | | - Maria Elena Ochoa
- Unidad de Cuidados Intensivos, Fundación Valle del Lili, Cali, Colombia
| | - Marcela Granados
- Unidad de Cuidados Intensivos, Fundación Valle del Lili, Cali, Colombia
| | - Ingrid Ruiz-Ordoñez
- GIRAT: Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional; Fundación Valle Del Lili and Universidad Icesi, Cali, Colombia
| | - Gabriel J Tobón
- GIRAT: Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional; Fundación Valle Del Lili and Universidad Icesi, Cali, Colombia
| |
Collapse
|
20
|
Etiologies and outcomes of rheumatology patients with acute respiratory failure requiring intensive care: a single-center medical records review study of 259 patients. Clin Rheumatol 2020; 39:3479-3488. [PMID: 32372293 DOI: 10.1007/s10067-020-05080-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/20/2020] [Accepted: 04/01/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The etiologies of acute respiratory failure in patients with systemic rheumatic diseases (SRDs) requiring intensive care remain unknown. This study was undertaken to investigate the etiologies and outcomes. METHODS A medical records review study was performed of 259 adult SRDs patients with respiratory failure admitted to medical ICU across a 5-year period. The etiologies were classified as infection, SRD exacerbation, and undetermined. The factors associated with ICU mortality were identified with multivariate logistic regression analysis. RESULTS The etiologies of respiratory failure included infection (n = 209, 80.7%), SRD exacerbation (n = 71, 27.4%), and undetermined (n = 21, 8.1%). The most common pathogen was Pneumocystis jirovecii (39.8%), followed by Aspergillus spp. (33.2%), and cytomegalovirus (23.2%). The ICU mortality rate was 59.8%. A high acute physiology and chronic health evaluation II score (OR 1.118, 95% CI 1.054 to 1.186, p < 0.001), a PaO2/FiO2 ratio < 100 mmHg (OR 3.918, 95% CI 2.199 to 6.892, p < 0.001), and a diagnosis of dermatomyositis/polymyositis (OR 4.898, 95% CI 1.949 to 12.309, p = 0.001), vasculitis (OR 3.007, 95% CI 1.237 to 7.309, p = 0.015), and Pneumocystis pneumonia (OR 2.345, 95% CI 1.168 to 4.705, p = 0.016) were associated with increased mortality. CONCLUSIONS Opportunistic infections and SRD exacerbation were the most common etiologies of acute respiratory failure in patients with SRDs requiring ICU admission, with high ICU mortality. Development of a standard protocol for differential diagnosis in this population might help initiate definitive therapy and improve clinical outcome. Key Points • Infections, especially with opportunistic infections, were the leading cause of acute respiratory failure in critically ill rheumatology patients, with high mortality. • Severity of illness, certain types of rheumatic diseases, and opportunistic fungal infections were associated with increased mortality. • Using a comprehensive diagnostic workup might help to confirm the infective etiology and improve outcome.
Collapse
|
21
|
Larcher R, Pineton de Chambrun M, Garnier F, Rubenstein E, Carr J, Charbit J, Chalard K, Mourad M, Amalric M, Platon L, Brunot V, Amoura Z, Jaber S, Jung B, Luyt CE, Klouche K. One-Year Outcome of Critically Ill Patients With Systemic Rheumatic Disease: A Multicenter Cohort Study. Chest 2020; 158:1017-1026. [PMID: 32289313 DOI: 10.1016/j.chest.2020.03.050] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 02/15/2020] [Accepted: 03/09/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Critically ill patients with systemic rheumatic disease (SRD) have benefited from better provision of rheumatic and critical care in recent years. Recent comprehensive data regarding in-hospital mortality rates and, most importantly, long-term outcomes are scarce. RESEARCH QUESTION The aim of this study was to assess short and long-term outcome of patients with SRD who were admitted to the ICU. STUDY DESIGN AND METHODS All records of patients with SRD who were admitted to ICU between 2006 and 2016 were reviewed. In-hospital and one-year mortality rates were assessed, and predictive factors of death were identified. RESULTS A total of 525 patients with SRD were included. Causes of admission were most frequently shock (40.8%) and acute respiratory failure (31.8%). Main diagnoses were infection (39%) and SRD flare-up (35%). In-hospital and one-year mortality rates were 30.5% and 37.7%, respectively. Predictive factors that were associated with in-hospital and one-year mortalities were, respectively, age, prior corticosteroid therapy, simplified acute physiology score II ≥50, need for invasive mechanical ventilation, or need for renal replacement therapy. Knaus scale C or D and prior conventional disease modifying antirheumatic drug therapy was associated independently with death one-year after ICU admission. INTERPRETATION Critically ill patients with SRD had a fair outcome after an ICU stay. Increased age, prior corticosteroid therapy, and severity of critical illness were associated significantly with short- and long-term mortality rates. The one-year mortality rate was also associated with prior health status and conventional disease modifying antirheumatic drug therapy.
Collapse
Affiliation(s)
- Romaric Larcher
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier, France; PhyMedExp, INSERM, CNRS, Montpellier, France.
| | - Marc Pineton de Chambrun
- Department of Internal Medicine 2, E3M Institute, Paris, France; Medical Intensive Care Unit, Institute of Cardiology, La Pitie-Salpetriere Hospital, University of Paris 6, Paris, France
| | - Fanny Garnier
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier, France; UPRES EA2415, Laboratory of biostatistics, Epidemiology, Clinical Research and Health Economics, University of Montpellier, Montpellier, France
| | - Emma Rubenstein
- Internal Medicine Department, Saint Louis Hospital, University of Paris 7, Assistance Publique - Hopitaux de Paris, Paris, France
| | - Julie Carr
- Anesthesiology and Intensive Care Departments, Saint Eloi Hospital, Montpellier, France
| | | | | | - Marc Mourad
- Arnaud de Villeneuve Hospital, University Hospital of Montpellier, Montpellier, France
| | - Matthieu Amalric
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier, France
| | - Laura Platon
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier, France
| | - Vincent Brunot
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier, France
| | - Zahir Amoura
- Department of Internal Medicine 2, E3M Institute, Paris, France
| | - Samir Jaber
- Anesthesiology and Intensive Care Departments, Saint Eloi Hospital, Montpellier, France; PhyMedExp, INSERM, CNRS, Montpellier, France
| | - Boris Jung
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier, France; PhyMedExp, INSERM, CNRS, Montpellier, France
| | - Charles-Edouard Luyt
- Medical Intensive Care Unit, Institute of Cardiology, La Pitie-Salpetriere Hospital, University of Paris 6, Paris, France
| | - Kada Klouche
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier, France; PhyMedExp, INSERM, CNRS, Montpellier, France
| |
Collapse
|
22
|
|
23
|
[Epidemiology and outcome of patients with rheumatic diseases in the intensive care unit]. Z Rheumatol 2019; 78:925-931. [PMID: 31468166 DOI: 10.1007/s00393-019-00693-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Patients with rheumatic diseases have an increased risk for admission to an intensive care unit (ICU) compared with individuals without these diseases. Besides cardiovascular events, infection complications are frequently the reason for ICU treatment. For autoimmune systemic diseases, such as systemic lupus erythematosus (SLE) and granulomatosis with polyangiitis (GPA), it is not uncommon for the disease to be first diagnosed during intensive medical care. In addition, flares of these diseases can necessitate ICU admission of the patients. The mortality of patients with rheumatic diseases on the ICU is increased compared with control collectives, especially in patients suffering from life-threatening infections. Treatment with corticosteroids is associated with an increased risk for ICU admission as well as a poorer survival rate. In contrast, patients treated with conventional and biologic disease-modifying anti-rheumatic drugs (DMARD) are less likely to need ICU treatment, compared with rheumatism patients without these medications. Among the established scoring systems applied to estimate the prognosis of ICU patients, the APACHE II score is the best investigated system in patients suffering from rheumatic diseases. This score probably reflects the condition of these patients better than other scoring systems.
Collapse
|
24
|
Hellmich B, Löffler C. [What are the indications for rescue procedures? : Systemic rheumatic diseases in the intensive care unit]. Z Rheumatol 2019; 78:955-966. [PMID: 31485728 PMCID: PMC7101899 DOI: 10.1007/s00393-019-00687-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Schwere, organ- oder lebensbedrohliche Manifestationen entzündlicher rheumatischer Erkrankungen, wie z. B. eine diffuse alveoläre Hämorrhagie im Rahmen einer Kleingefäßvaskulitis, sprechen nicht immer ausreichend oder mit zeitlicher Verzögerung auf eine immunsuppressive Therapie an. Bei einem drohenden oder bereits eingetretenen Organversagen besteht dann nicht selten die Notwendigkeit, die immunsuppressive Therapie auf der Intensivstation um rasch wirksame Rescue-Therapieverfahren zu ergänzen. Aufgrund der Seltenheit vieler rheumatischer Erkrankungen ist die Evidenz zum Einsatz von Rescue-Therapieverfahren wie der Plasmapherese, der extrakorporalen Membranoxygenierung (ECMO) oder der Gabe von intravenösen Immunglobulinen (IVIG) für viele Indikationen eher gering. Der Einsatz der Plasmapherese wird bei einer akuten Anti-GBM(glomeruläre Basalmembran)-Erkrankung (Goodpasture Syndrom) oder einem katastrophalen Antiphospholipidantikörpersyndrom (CAPS) als sinnvoll angesehen. Eine ECMO-Therapie kann bei persistierender respiratorischer Insuffizienz trotz mechanischer Beatmung als Folge einer diffusen alveolären Hämorrhagie oder eines Acute-Respiratory-Distress-Syndroms (ARDS) anderer Ursache erwogen werden. Eine Gabe von IVIG ist bei einer akuten kardialen Beteiligung im Rahmen einer Kawasaki-Erkrankung indiziert und kann beim CAPS sowie bei therapierefraktären Myositiden erwogen werden.
Collapse
Affiliation(s)
- B Hellmich
- Vaskulitiszentrum Süd, Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken - Akademisches Lehrkrankenhaus, Universität Tübingen, Eugenstr. 3, 73230, Kirchheim u. Teck, Deutschland.
| | - C Löffler
- Vaskulitiszentrum Süd, Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken - Akademisches Lehrkrankenhaus, Universität Tübingen, Eugenstr. 3, 73230, Kirchheim u. Teck, Deutschland
| |
Collapse
|
25
|
Restrepo-Escobar M, A Ríos N, Hernández-Zapata LJ, Velásquez M, Eraso R. Factors associated with infection amongst paediatric patients with systemic lupus erythematosus treated in the intensive care unit. Lupus 2019; 28:1141-1147. [DOI: 10.1177/0961203319860194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Objective To identify determinants and outcomes associated with infection in paediatric systemic lupus erythematosus (SLE) patients at admission and during hospitalization in intensive care units (ICUs). Patients and methods A retrospective cohort study of paediatric SLE patients admitted to two ICUs was conducted. Frequency and risk factors of infection as well as mortality were studied. Results Seventy-three infection episodes amongst 55 patients were analysed. The median age was 14.4 years (IQR 12.5–16). The median SLEDAI was 16 (IQR 12–20). Twenty-nine episodes were documented at admission; the CRP was higher in these patients (6.58 versus 1.04 mg/dl, p<0.001) than in non-infected patients, even after multivariate adjustment (OR 8.6, 95% CI = 2.1–34.8, p = 0.003). Twenty-five (34.7%) episodes occurred during hospitalization. Lupus activity (OR 1.14, 95% CI = 1.01–1.27, p = 0.029), cyclophosphamide (OR 17.9, 95% CI = 2–156, p = 0.009) and mechanical ventilation (OR 16, 95% CI = 2.1–122, p = 0.008) were associated with infection. Ten episodes (14%) led to death. Admission to the ICU due to infection was strongly associated with mortality (90% versus 31.8%, OR 19.4, 95% CI = 2.3–163, p = 0.006). Conclusion In paediatric lupus patients admitted to the ICU, elevated CRP should alert clinicians to possible infection. During hospitalization, SLE activity and cyclophosphamide were associated with infection. Infection at admission to the ICU was strongly associated with mortality.
Collapse
Affiliation(s)
- M Restrepo-Escobar
- University of Antioquia, Medellín, Colombia
- Pablo Tobón Uribe Hospital, Medellín, Colombia
| | - N A Ríos
- University of Antioquia, Medellín, Colombia
| | | | - M Velásquez
- San Vicente Fundación University Hospital, Medellín, Colombia
| | - R Eraso
- University of Antioquia, Medellín, Colombia
- Pablo Tobón Uribe Hospital, Medellín, Colombia
| |
Collapse
|
26
|
Patients with small-vessel vasculitides have the highest mortality among systemic autoimmune diseases patients treated in intensive care unit: A retrospective study with 5-year follow-up. J Crit Care 2018; 48:166-171. [DOI: 10.1016/j.jcrc.2018.08.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 08/24/2018] [Accepted: 08/25/2018] [Indexed: 01/06/2023]
|
27
|
Abstract
BACKGROUND AND OBJECTIVE Very little is known about the outcome of patients with inflammatory rheumatic diseases in intensive care units (ICU). This retrospective study investigated the results of intensive medical treatment in these patients and the reliability of scoring systems used for the prediction of survival. MATERIAL AND METHODS A case group consisting of 50 patients suffering from inflammatory rheumatic diseases was generated by analysis of patient records from the ICU at the University Hospital for Internal Medicine in Halle (Saale) in the years 2001-2010. The APACHE II score and SAPS II were used to estimate the probable mortality rate. The data were compared to those of a control group consisting of 72 patients treated on the ICU and suffering from non-inflammatory joint diseases. RESULTS In the case group a higher mortality rate (38 % vs. 20.8 %) and a higher frequency of respiratory, nephrogenic and cardiovascular complications were observed. In addition, these patients more often underwent artificial ventilation (66 % vs. 35 %) and had a higher rate of infections (74 % vs. 40.3 %) compared to the control group. In patients with inflammatory rheumatic diseases the SAPS II was not useful for correctly predicting mortality, whereas the APACHE II score showed sufficient agreement with the actual mortality rate. CONCLUSION Patients with inflammatory rheumatic diseases displayed a poorer outcome compared with the control group in the course of the intensive care treatment. Universally applied scoring systems used to predict mortality are of limited value in this patient population.
Collapse
|
28
|
Risk of adverse outcomes in patients with rheumatoid arthritis hospitalized for stroke-a cross-sectional study. Clin Rheumatol 2018; 37:2917-2926. [PMID: 30209695 DOI: 10.1007/s10067-018-4287-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/27/2018] [Accepted: 09/03/2018] [Indexed: 10/28/2022]
Abstract
Specific data regarding the full range of stroke outcomes among patients with rheumatoid arthritis (RA) are lacking. This study aimed to investigate outcomes in RA patients hospitalized for a stroke. The study retrieved data from the Taiwan Longitudinal Health Insurance Database 2005. We identified 26,336 patients who were hospitalized for stroke treatment. Of these patients, 736 patients with a prior diagnosis of RA before the index hospitalization were selected as the study group. We selected 2208 age-sex-matched patients without RA as the comparison group. We performed conditional logistic regressions to calculate odds ratios (ORs) for in-hospital mortality and secondary diagnoses of pneumonia, urinary tract infections (UTIs), peptic ulcers, acute respiratory failure, and the use of mechanical ventilation to compare RA patients and comparison patients. We also compared the length of stay (LOS) and hospitalization costs between patients with RA and comparison patients. We found that RA patients had a significantly increased risk of peptic ulcer during the stroke hospitalization (OR = 1.52, 95% CI = 1.05-2.20). However, there were no significant differences between patients with RA and comparison patients in terms of in-hospital mortality, pneumonia, UTIs, acute respiratory failure, or the use of mechanical ventilation. Furthermore, the LOS of stroke hospitalization did not differ between the two groups. We concluded that RA patients hospitalized for a stroke do not have a significantly different risk of in-hospital mortality, pneumonia, UTIs, and mechanical ventilator use, but they have a higher risk of peptic ulcers. Additionally, among patients with a subarachnoid/intracerebral hemorrhagic stroke, RA patients were more likely to have received mechanical ventilation than comparison patients (adjusted OR = 1.89, 95% CI = 1.14-3.15).
Collapse
|
29
|
Delvino P, Monti S, Balduzzi S, Belliato M, Montecucco C, Caporali R. The role of extra-corporeal membrane oxygenation (ECMO) in the treatment of diffuse alveolar haemorrhage secondary to ANCA-associated vasculitis: report of two cases and review of the literature. Rheumatol Int 2018; 39:367-375. [PMID: 30074077 DOI: 10.1007/s00296-018-4116-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 07/28/2018] [Indexed: 01/19/2023]
Abstract
Diffuse alveolar haemorrhage (DAH) secondary to anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) is a rare life-threatening condition presenting with severe respiratory failure. The management of AAV-related DAH consists of remission induction immunosuppressive therapy, which requires time to be effective, with significant fatality rates despite appropriate treatment. Extracorporeal membrane oxygenation (ECMO) can support gas exchanges providing the time necessary for immunosuppressive treatment to control the underlying disease in cases refractory to the conventional ventilation techniques. Despite severe preexisting bleeding has been considered a relative contraindication, ECMO has proven to be life-saving in several cases of respiratory failure associated with pulmonary haemorrhage due to various causes, including AAV. We reviewed the clinical presentation and course of two patients affected by AAV-related DAH treated at our Institution between 2012 and 2017, whose management required the use of veno-venous ECMO. We reviewed the current literature on the role of ECMO in the support of these patients. In both patients, ECMO provided life support and allowed disease control, in combination with immunosuppressive treatment. Despite systemic anticoagulation, clinical improvement was achieved without exacerbation of the pulmonary bleeding. We performed a literature review, and summarized available data confirming the effectiveness and safety of ECMO in AAV-related DAH. ECMO has a life-saving role in the management of patients with severe respiratory failure due to ANCA-associated pulmonary capillaritis.
Collapse
Affiliation(s)
- Paolo Delvino
- Rheumatology Department, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy.
| | - Sara Monti
- Rheumatology Department, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy.,University of Pavia, Pavia, Italy
| | - Silvia Balduzzi
- Rheumatology Department, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
| | - Mirko Belliato
- UOS Advanced Respiratory Intensive Care Unit, UOC Anestesia e Rianimazione 1, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Carlomaurizio Montecucco
- Rheumatology Department, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
| | - Roberto Caporali
- Rheumatology Department, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pz.le Golgi 2, 27100, Pavia, Italy
| |
Collapse
|
30
|
Patients with systemic rheumatic diseases admitted to the intensive care unit: what the rheumatologist needs to know. Rheumatol Int 2018; 38:1163-1168. [PMID: 29549383 DOI: 10.1007/s00296-018-4008-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 03/09/2018] [Indexed: 10/17/2022]
Abstract
Patients with systemic rheumatic diseases (SRDs) may require admission to the intensive care unit (ICU) throughout the course of their disease. Therefore, the rheumatologist needs an understanding of the factors which may influence the course of patients with SRDs who are admitted to ICU. These include the causes for admission, patient characteristics including comorbidities and drug therapies, outcome (in-ICU mortality and causes of death), and prognostic factors. Infections and exacerbation/complications of SRDs are the most common (and potentially reversible) reasons for both admission and death on ICU. Mortality in patients with SRDs admitted to ICU has been reported to be either no different or higher than 'general' ICU patients. Reported prognostic factors included patient and disease characteristics, as well as ICU factors, including scoring systems. Rheumatologists need to be aware of the factors surrounding admission of patients with SRDs to ICU, including the need for strong links with critical care medicine.
Collapse
|
31
|
Grasselli G, Vergnano B, Pozzi MR, Sala V, D'Andrea G, Scaravilli V, Mantero M, Pesci A, Pesenti A. Interstitial pneumonia with autoimmune features: an additional risk factor for ARDS? Ann Intensive Care 2017; 7:98. [PMID: 28921478 PMCID: PMC5603462 DOI: 10.1186/s13613-017-0320-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 09/07/2017] [Indexed: 12/22/2022] Open
Abstract
Background Interstitial pneumonia with autoimmune features (IPAF) identifies a recently recognized autoimmune syndrome characterized by interstitial lung disease and autoantibodies positivity, but absence of a specific connective tissue disease diagnosis or alternative etiology. We retrospectively reviewed the clinical presentation, diagnostic workup and management of seven critically ill patients who met diagnostic criteria for IPAF. We compared baseline characteristics and clinical outcome of IPAF patients with those of the population of ARDS patients admitted in the same period. Results Seven consecutive patients with IPAF admitted to intensive care unit for acute respiratory distress syndrome (ARDS) were compared with 78 patients with ARDS secondary to a known risk factor and with eight ARDS patients without recognized risk factors. Five IPAF patients (71%) survived and were discharged alive from ICU: Their survival rate was equal to that of patients with a known risk factor (71%), while the subgroup of patients without risk factors had a markedly lower survival (38%). According to the Berlin definition criteria, ARDS was severe in four IPAF patients and moderate in the remaining three. All had multiple organ dysfunction at presentation. The most frequent autoantibody detected was anti-SSA/Ro52. All patients required prolonged mechanical ventilation (median duration 49 days, range 10–88); four received extracorporeal membrane oxygenation and one received low-flow extracorporeal CO2 removal. All patients received immunosuppressive therapy. Conclusions This is the first description of a cohort of critical patients meeting the diagnostic criteria for IPAF presenting with ARDS. This diagnosis should be considered in any critically ill patient with interstitial lung disease of unknown origin. While management is challenging and level of support high, survival appears to be good and comparable to that of patients with ARDS associated with a known clinical insult Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0320-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Giacomo Grasselli
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.
| | - Beatrice Vergnano
- Dipartimento di Emergenza-Urgenza, Ospedale San Gerardo, Monza, Italy
| | - Maria Rosa Pozzi
- Dipartimento di Medicina, Unità Operativa di Reumatologia, Ospedale San Gerardo, Monza, Italy
| | - Vittoria Sala
- Dipartimento di Emergenza-Urgenza, Ospedale San Gerardo, Monza, Italy
| | - Gabriele D'Andrea
- Unità Operativa di Radiodiagnostica, Ospedale San Gerardo, Monza, Italy
| | - Vittorio Scaravilli
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Marco Mantero
- Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Alberto Pesci
- Dipartimento di Medicina e Chirurgia, Università Milano Bicocca, Monza, Italy.,Clinica Pneumologica, Ospedale San Gerardo, Monza, Italy
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.,Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| |
Collapse
|
32
|
Beil M, Sviri S, de la Guardia V, Stav I, Ben-Chetrit E, van Heerden PV. Prognosis of patients with rheumatic diseases admitted to intensive care. Anaesth Intensive Care 2017; 45:67-72. [PMID: 28072937 DOI: 10.1177/0310057x1704500110] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Variable mortality rates have been reported for patients with rheumatic diseases admitted to an intensive care unit (ICU). Due to the absence of appropriate control groups in previous studies, it is not known whether the presence of a rheumatic disease constitutes a risk factor. Moreover, the accuracy of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score for predicting outcome in this group of patients has been questioned. The primary goal of this study was to compare outcome of patients with rheumatic diseases admitted to a medical ICU to those of controls. The records of all patients admitted between 1 April 2003 and 30 June 2014 (n=4020) were screened for the presence of a rheumatic disease during admission (n=138). The diagnosis of a rheumatic disease was by standard criteria for these conditions. An age- and gender-matched control group of patients without a rheumatic disease was extracted from the patient population in the database during the same period (n=831). Mortality in ICU, in hospital and after 180 days did not differ significantly between patients with and without rheumatic diseases. There was no difference in the performance of the APACHE II score for predicting outcome in patients with rheumatic diseases and controls. This score, as well as a requirement for the use of inotropes or vasopressors, accurately predicted hospital mortality in the group of patients with rheumatic diseases. In conclusion, patients with a rheumatic condition admitted to intensive care do not do significantly worse than patients without such a disease.
Collapse
Affiliation(s)
- M Beil
- Visiting Professor, Medical Intensive Care Unit, Hadassah University Hospital, En Kerem, Jerusalem, Israel, University of Ulm, Germany
| | - S Sviri
- Director, Medical Intensive Care Unit, Hadassah University Hospital, En Kerem, Jerusalem, Israel
| | - V de la Guardia
- Fellow, Medical Intensive Care Unit, Hadassah University Hospital, En Kerem, Jerusalem, Israel
| | - I Stav
- Data Analyst, Medical Intensive Care Unit, Hadassah University Hospital, En Kerem, Jerusalem, Israel
| | - E Ben-Chetrit
- Professor, Rheumatology Unit, Hadassah University Hospital, En Kerem, Jerusalem, Israel
| | - P V van Heerden
- Professor of Anesthesiology, General Intensive Care Unit, Hadassah University Hospital, En Kerem, Jerusalem, Israel
| |
Collapse
|
33
|
Olsen NJ, Choi MY, Fritzler MJ. Emerging technologies in autoantibody testing for rheumatic diseases. Arthritis Res Ther 2017; 19:172. [PMID: 28738887 PMCID: PMC5525353 DOI: 10.1186/s13075-017-1380-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Testing for the presence of antinuclear antibodies (ANAs) is a key step in the diagnosis of systemic lupus erythematosus (SLE) and other systemic autoimmune rheumatic diseases (SARD). The standard slide-based indirect immunofluorescence (IIF) test is widely used, but is limited by a relative lack of specificity for SLE and not all SARD-ANAs are detected. Alternative immunoassays that might offer enhanced diagnostic and prognostic information have evolved, and some of these have entered clinical practice. This review summarizes the current state of ANA testing and multiplex techniques for detecting other autoantibodies, the possibility of point-of-care testing, and approaches for applications in early disease stages.
Collapse
Affiliation(s)
- Nancy J Olsen
- Penn State M.S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA.
| | - May Y Choi
- Cumming School of Medicine, University of Calgary, Calgary, AB, T2N4N1, Canada
| | - Marvin J Fritzler
- Cumming School of Medicine, University of Calgary, Calgary, AB, T2N4N1, Canada
| |
Collapse
|
34
|
Cinquanta L, Fontana DE, Bizzaro N. Chemiluminescent immunoassay technology: what does it change in autoantibody detection? AUTOIMMUNITY HIGHLIGHTS 2017. [PMID: 28647912 PMCID: PMC5483212 DOI: 10.1007/s13317-017-0097-2] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Diagnostic technology is rapidly evolving, and over the last decade, substantial progress has been made even for the identification of antibodies, increasingly approaching this type of diagnostic to that of automated clinical chemistry laboratory. In this review, we describe the analytical and diagnostic characteristics of chemiluminescence technology in its strength and in its applicability for a more rapid and accurate diagnosis of autoimmune diseases. The wide dynamic range, greater than that of immunoenzymatic methods, the high sensitivity and specificity of the results expressed in quantitative form, the high degree of automation and the clinical implications related to the reduction in the turnaround time, and the ability to run a large number of antibody tests (even of different isotypes), directed towards large antigenic panels in random access mode, make this technology the most advanced in the clinical laboratory, with enormous repercussions on the workflow and on the autoimmunology laboratory organisation. Further improvements are expected in the coming years with the development of new analytical platforms such as the flow-injection chemiluminescent immunoassay, the two-dimensional resolution for chemiluminescence multiplex immunoassay and the magnetic nanoparticles chemiluminescence immunoassay, which will likely result in additional increases in the clinical efficacy of antibody tests.
Collapse
Affiliation(s)
- Luigi Cinquanta
- Autoimmunologia e Allergologia Diagnostica di Laboratorio, UOC di Patologia Clinica, Azienda Ospedaliera Universitaria "Scuola Medica Salernitana", OORR San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy.
| | - Desré Ethel Fontana
- Dipartimento di Medicina di Laboratorio e Istituto di Patologia Clinica, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Nicola Bizzaro
- Laboratorio di Patologia Clinica, Ospedale San Antonio, Azienda Sanitaria Universitaria Integrata di Udine, Tolmezzo, Italy
| |
Collapse
|
35
|
Camargo JF, Tobón GJ, Fonseca N, Diaz JL, Uribe M, Molina F, Anaya JM. Autoimmune rheumatic diseases in the intensive care unit: experience from a tertiary referral hospital and review of the literature. Lupus 2016; 14:315-20. [PMID: 15864918 DOI: 10.1191/0961203305lu2082oa] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Autoimmune rheumatic diseases (AIRD) are not uncommon in the general population and up to one third of hospitalized patients with AIRD may need admission to intensive care unit (ICU). This paper describes the causes of admission, the clinical features and outcome of 24 AIRD patients admitted to a medical ICU from a third level hospital. Thirteen patients had systemic lupus erythematosus (54.2%), three rheumatoid arthritis (12.5%), three pulmonary renal syndrome (12.5%), two dermatopolymyositis (8.3%), two scleroderma (8.3%) and one antiphospholipid syndrome (4.2%). The main causes for ICU admission were rheumatic disease flare-up (37.5%), infection (37.5%) and complications derived from rheumatic disease (29.1%). Mortality during ICU stay was 16.7% (four patients). Excluding shock requiring vasopressor support, no statistical difference was found between survivors and nonsurvivors; although there was a trend to higher test severity scores (APACHE II, ODIN) in nonsurvivors. Our results reveal a lower mortality rate in AIRD patients admitted to the ICU than reported previously. Severity scores such as APACHE II are predictors of mortality in patients with AIRD in the ICU.
Collapse
Affiliation(s)
- J F Camargo
- Rheumatology Unit, Clínica Universitaria Bolivariana, Medellin, Colombia, South America
| | | | | | | | | | | | | |
Collapse
|
36
|
|
37
|
Papiris SA, Manali ED, Kolilekas L, Kagouridis K, Maniati M, Filippatos G, Bouros D. Acute Respiratory Events in Connective Tissue Disorders. Respiration 2016; 91:181-201. [PMID: 26938462 DOI: 10.1159/000444535] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Subacute-acute, hyperacute, or even catastrophic and fulminant respiratory events occur in almost all classic connective tissue disorders (CTDs); they may share systemic life-threatening manifestations, may precipitously lead to respiratory failure requiring ventilatory support as well as a combination of specific therapeutic measures, and in most affected patients constitute the devastating end-of-life event. In CTDs, acute respiratory events may be related to any respiratory compartment including the airways, lung parenchyma, alveolar capillaries, lung vessels, pleura, and ventilatory muscles. Acute respiratory events may also precipitate disease-specific extrapulmonary organ involvement such as aspiration pneumonia and lead to digestive tract involvement and heart-related respiratory events. Finally, antirheumatic drug-related acute respiratory toxicity as well as lung infections related to the rheumatic disease and/or to immunosuppression complete the spectrum of acute respiratory events. Overall, in CTDs the lungs significantly contribute to morbidity and mortality, since they constitute a common site of disease involvement; a major site of infections related to the 'mater' disease; a major site of drug-related toxicity, and a common site of treatment-related infectious complications. The extreme spectrum of the abovementioned events, as well as the 'vicious' coexistence of most of the aforementioned manifestations, requires skills, specific diagnostic and therapeutic means, and most of all a multidisciplinary approach of adequately prepared and expert scientists. Avoiding lung disease might represent a major concern for future advancements in the treatment of autoimmune disorders.
Collapse
Affiliation(s)
- Spyros A Papiris
- 2nd Department of Pneumonology, x2018;Attikon' University Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | | | | | | |
Collapse
|
38
|
Dumas G, Géri G, Montlahuc C, Chemam S, Dangers L, Pichereau C, Brechot N, Duprey M, Mayaux J, Schenck M, Boisramé-Helms J, Thomas G, Baboi L, Mouthon L, Amoura Z, Papo T, Mahr A, Chevret S, Chiche JD, Azoulay E. Outcomes in critically ill patients with systemic rheumatic disease: a multicenter study. Chest 2016; 148:927-935. [PMID: 25996557 DOI: 10.1378/chest.14-3098] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Patients with systemic rheumatic diseases (SRDs) may require ICU management for SRD exacerbation or treatment-related infections or toxicities. METHODS This was an observational study at 10 university-affiliated ICUs in France. Consecutive patients with SRDs were included. Determinants of ICU mortality were identified through multivariable logistic analysis. RESULTS Three hundred sixty-three patients (65.3% women; median age, 59 years [interquartile range, 42-70 years]) accounted for 381 admissions. Connective tissue disease (primarily systemic lupus erythematosus) accounted for 66.1% of SRDs and systemic vasculitides for 26.2% (chiefly antineutrophil cytoplasm antibodies-associated vasculitides). SRDs were newly diagnosed in 43 cases (11.3%). Direct admission to the ICU occurred in 143 cases (37.9%). Reasons for ICU admissions were infection (39.9%), SRD exacerbation (34.4%), toxicity (5.8%), or miscellaneous (19.9%). Respiratory involvement was the leading cause of admission (56.8%), followed by shock (41.5%) and acute kidney injury (42.2%). Median Sequential Organ Failure Assessment (SOFA) score on day 1 was 5 (3-8). Mechanical ventilation was required in 57% of cases, vasopressors in 33.9%, and renal replacement therapy in 28.1%. ICU mortality rate was 21.0% (80 deaths). Factors associated with ICU mortality were shock (OR, 3.77; 95% CI, 1.93-7.36), SOFA score at day 1 (OR, 1.19; 95% CI, 1.10-1.30), and direct admission (OR, 0.52; 95% CI, 0.28-0.97). Neither comorbidities nor SRD characteristics were associated with survival. CONCLUSIONS In patients with SRDs, critical care management is mostly needed only in patients with a previously known SRD; however, diagnosis can be made in the ICU for 12% of patients. Infection and SRD exacerbation account for more than two-thirds of these situations, both targeting chiefly the lungs. Direct admission to the ICU may improve outcomes.
Collapse
Affiliation(s)
- Guillaume Dumas
- Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Paris
| | - Guillaume Géri
- Medical Intensive Care Unit, Cochin Teaching Hospital, Paris
| | | | - Sarah Chemam
- Medical Intensive Care Unit, Bichat Hospital, Paris
| | - Laurence Dangers
- Service de réanimation médicale, Institut de Cardiologie, Pitié-Salpêtrière Teaching Hospital, Paris
| | | | - Nicolas Brechot
- Service de réanimation médicale, Institut de Cardiologie, Pitié-Salpêtrière Teaching Hospital, Paris
| | - Matthieu Duprey
- Service de réanimation médicale, Institut de Cardiologie, Pitié-Salpêtrière Teaching Hospital, Paris
| | - Julien Mayaux
- Medical Intensive Care Unit, Pitié-Salpêtrière Teaching Hospital, Paris
| | - Maleka Schenck
- Medical Intensive Care Unit, Hautepierre Teaching Hospital, Strasbourg
| | - Julie Boisramé-Helms
- Medical Intensive Care Unit, Nouvel Hôpital Civil, Strasbourg Teaching Hospital, Strasbourg
| | - Guillemette Thomas
- Assistance-Publique-Hôpitaux de Marseille, Hôpital Nord, Réanimation des Détresses respiratoires et des Infections Sévères, Marseille
| | | | - Luc Mouthon
- Université Paris-Descartes, Department of Internal Medicine, Cochin Teaching Hospital, Paris, France
| | - Zair Amoura
- Department of Internal Medicine, Pitié-Salpêtrière Teaching Hospital, Paris
| | - Thomas Papo
- Assistance-Publique-Hôpitaux de Marseille, Hôpital Nord, Réanimation des Détresses respiratoires et des Infections Sévères, Marseille; Department of Internal Medicine, Bichat Hospital, Paris
| | - Alfred Mahr
- Department of Internal Medicine, Saint-Louis Teaching Hospital, Paris
| | - Sylvie Chevret
- Biostatistics Department, Saint-Louis Teaching Hospital, Paris
| | | | - Elie Azoulay
- Medical Intensive Care Unit, Saint-Louis Teaching Hospital, Paris.
| |
Collapse
|
39
|
Bernal-Macías S, Reyes-Beltrán B, Molano-González N, Augusto Vega D, Bichernall C, Díaz LA, Rojas-Villarraga A, Anaya JM. Outcome of patients with autoimmune diseases in the intensive care unit: a mixed cluster analysis. Lupus Sci Med 2015; 2:e000122. [PMID: 26688741 PMCID: PMC4680590 DOI: 10.1136/lupus-2015-000122] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 10/30/2015] [Accepted: 10/31/2015] [Indexed: 12/11/2022]
Abstract
Objectives The interest on autoimmune diseases (ADs) and their outcome at the intensive care unit (ICU) has increased due to the clinical challenge for diagnosis and management as well as for prognosis. The current work presents a-year experience on these topics in a tertiary hospital. Methods The mixed-cluster methodology based on multivariate descriptive methods such as principal component analysis and multiple correspondence analyses was performed to summarize sets of related variables with strong associations and common clinical context. Results Fifty adult patients with ADs with a mean age of 46.7±17.55 years were assessed. The two most common diagnoses were systemic lupus erythematosus and systemic sclerosis, registered in 45% and 20% of patients, respectively. The main causes of admission to ICU were infection and AD flare up, observed in 36% and 24%, respectively. Mortality during ICU stay was 24%. The length of hospital stay before ICU admission, shock, vasopressors, mechanical ventilation, abdominal sepsis, Glasgow score and plasmapheresis were all factors associated with mortality. Two new clinical clusters variables (NCVs) were defined: Time ICU and ICU Support Profile, which were associated with survivor and no survivor variables. Conclusions Identification of single factors and groups of factors from NCVs will allow implementation of early and aggressive therapies in patients with ADs at the ICU in order to avoid fatal outcomes
Collapse
Affiliation(s)
- Santiago Bernal-Macías
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
- Intensive Care Unit, Mederi, Hospital Universitario Mayor, Bogotá, Colombia
| | - Benjamín Reyes-Beltrán
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
- Intensive Care Unit, Mederi, Hospital Universitario Mayor, Bogotá, Colombia
| | - Nicolás Molano-González
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | | | - Claudia Bichernall
- Intensive Care Unit, Mederi, Hospital Universitario Mayor, Bogotá, Colombia
| | | | - Adriana Rojas-Villarraga
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
- Intensive Care Unit, Mederi, Hospital Universitario Mayor, Bogotá, Colombia
| | - Juan-Manuel Anaya
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
- Intensive Care Unit, Mederi, Hospital Universitario Mayor, Bogotá, Colombia
| |
Collapse
|
40
|
Peschken CA, Hitchon CA, Garland A, Bernstein CN, Chen H, Fransoo R, Marrie RA. A Population-based Study of Intensive Care Unit Admissions in Rheumatoid Arthritis. J Rheumatol 2015; 43:26-33. [PMID: 26628597 DOI: 10.3899/jrheum.150312] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2015] [Indexed: 01/22/2023]
Abstract
OBJECTIVE We aimed to determine the incidence of and mortality after critical illness in rheumatoid arthritis (RA) compared with the general population, and to describe the risks for and characteristics of critical illness in patients with RA. METHODS We used population-based administrative data from the Data Repository at the Manitoba Centre for Health Policy from 1984 to 2010, and linked clinical data from an intensive care unit (ICU) database to identify all persons with RA in the province requiring ICU admission. We identified a population-based control group, matched by age, sex, socioeconomic status, and region of residence. The incidence of ICU admission, reasons for, and mortality after ICU admission were compared between populations using age- and sex-standardized rates, rate ratios, Cox proportional hazards models, and logistic regression models. RESULTS We identified 10,078 prevalent and 5560 incident cases of RA. After adjustment, the risk for ICU admission was higher for RA (HR 1.65, 95% CI 1.50-1.83) versus the matched general population. From 2000-2010, the annual incidence of ICU admission among prevalent patients was about 1% in RA, with a crude 10-year incidence of 8%. Compared with the general population admitted to ICU, 1 year after ICU admission, mortality was increased by 40% in RA. Cardiovascular disorders were the most common reason for ICU admission in RA. CONCLUSION Patients with RA have a higher risk for admission to the ICU than the general population and increased mortality 1 year after admission. Even with advances in management, RA remains a serious disease with significant morbidity.
Collapse
Affiliation(s)
- Christine A Peschken
- From the Department of Internal Medicine, and Department of Community Health Sciences, and Manitoba Centre for Health Policy, and the IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada.C.A. Peschken, MD, MSc, FRCPC, Associate Professor, Department of Internal Medicine, and Department of Community Health Sciences, University of Manitoba; C.A. Hitchon, MD, MSc, Department of Internal Medicine, University of Manitoba; A. Garland, MD, MA, Department of Internal Medicine, and Department of Community Health Sciences, and Manitoba Centre for Health Policy, University of Manitoba;C.N. Bernstein, MD, Department of Internal Medicine, and IBD Clinical and Research Centre, University of Manitoba; H. Chen, MSc, Manitoba Centre for Health Policy, University of Manitoba; R. Fransoo, PhD, Department of Community Health Sciences, and Manitoba Centre for Health Policy, University of Manitoba; R.A. Marrie, MD, PhD, Department of Internal Medicine, and Department of Community Health Sciences, University of Manitoba.
| | - Carol A Hitchon
- From the Department of Internal Medicine, and Department of Community Health Sciences, and Manitoba Centre for Health Policy, and the IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada.C.A. Peschken, MD, MSc, FRCPC, Associate Professor, Department of Internal Medicine, and Department of Community Health Sciences, University of Manitoba; C.A. Hitchon, MD, MSc, Department of Internal Medicine, University of Manitoba; A. Garland, MD, MA, Department of Internal Medicine, and Department of Community Health Sciences, and Manitoba Centre for Health Policy, University of Manitoba;C.N. Bernstein, MD, Department of Internal Medicine, and IBD Clinical and Research Centre, University of Manitoba; H. Chen, MSc, Manitoba Centre for Health Policy, University of Manitoba; R. Fransoo, PhD, Department of Community Health Sciences, and Manitoba Centre for Health Policy, University of Manitoba; R.A. Marrie, MD, PhD, Department of Internal Medicine, and Department of Community Health Sciences, University of Manitoba
| | - Allan Garland
- From the Department of Internal Medicine, and Department of Community Health Sciences, and Manitoba Centre for Health Policy, and the IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada.C.A. Peschken, MD, MSc, FRCPC, Associate Professor, Department of Internal Medicine, and Department of Community Health Sciences, University of Manitoba; C.A. Hitchon, MD, MSc, Department of Internal Medicine, University of Manitoba; A. Garland, MD, MA, Department of Internal Medicine, and Department of Community Health Sciences, and Manitoba Centre for Health Policy, University of Manitoba;C.N. Bernstein, MD, Department of Internal Medicine, and IBD Clinical and Research Centre, University of Manitoba; H. Chen, MSc, Manitoba Centre for Health Policy, University of Manitoba; R. Fransoo, PhD, Department of Community Health Sciences, and Manitoba Centre for Health Policy, University of Manitoba; R.A. Marrie, MD, PhD, Department of Internal Medicine, and Department of Community Health Sciences, University of Manitoba
| | - Charles N Bernstein
- From the Department of Internal Medicine, and Department of Community Health Sciences, and Manitoba Centre for Health Policy, and the IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada.C.A. Peschken, MD, MSc, FRCPC, Associate Professor, Department of Internal Medicine, and Department of Community Health Sciences, University of Manitoba; C.A. Hitchon, MD, MSc, Department of Internal Medicine, University of Manitoba; A. Garland, MD, MA, Department of Internal Medicine, and Department of Community Health Sciences, and Manitoba Centre for Health Policy, University of Manitoba;C.N. Bernstein, MD, Department of Internal Medicine, and IBD Clinical and Research Centre, University of Manitoba; H. Chen, MSc, Manitoba Centre for Health Policy, University of Manitoba; R. Fransoo, PhD, Department of Community Health Sciences, and Manitoba Centre for Health Policy, University of Manitoba; R.A. Marrie, MD, PhD, Department of Internal Medicine, and Department of Community Health Sciences, University of Manitoba
| | - Hui Chen
- From the Department of Internal Medicine, and Department of Community Health Sciences, and Manitoba Centre for Health Policy, and the IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada.C.A. Peschken, MD, MSc, FRCPC, Associate Professor, Department of Internal Medicine, and Department of Community Health Sciences, University of Manitoba; C.A. Hitchon, MD, MSc, Department of Internal Medicine, University of Manitoba; A. Garland, MD, MA, Department of Internal Medicine, and Department of Community Health Sciences, and Manitoba Centre for Health Policy, University of Manitoba;C.N. Bernstein, MD, Department of Internal Medicine, and IBD Clinical and Research Centre, University of Manitoba; H. Chen, MSc, Manitoba Centre for Health Policy, University of Manitoba; R. Fransoo, PhD, Department of Community Health Sciences, and Manitoba Centre for Health Policy, University of Manitoba; R.A. Marrie, MD, PhD, Department of Internal Medicine, and Department of Community Health Sciences, University of Manitoba
| | - Randy Fransoo
- From the Department of Internal Medicine, and Department of Community Health Sciences, and Manitoba Centre for Health Policy, and the IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada.C.A. Peschken, MD, MSc, FRCPC, Associate Professor, Department of Internal Medicine, and Department of Community Health Sciences, University of Manitoba; C.A. Hitchon, MD, MSc, Department of Internal Medicine, University of Manitoba; A. Garland, MD, MA, Department of Internal Medicine, and Department of Community Health Sciences, and Manitoba Centre for Health Policy, University of Manitoba;C.N. Bernstein, MD, Department of Internal Medicine, and IBD Clinical and Research Centre, University of Manitoba; H. Chen, MSc, Manitoba Centre for Health Policy, University of Manitoba; R. Fransoo, PhD, Department of Community Health Sciences, and Manitoba Centre for Health Policy, University of Manitoba; R.A. Marrie, MD, PhD, Department of Internal Medicine, and Department of Community Health Sciences, University of Manitoba
| | - Ruth Ann Marrie
- From the Department of Internal Medicine, and Department of Community Health Sciences, and Manitoba Centre for Health Policy, and the IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada.C.A. Peschken, MD, MSc, FRCPC, Associate Professor, Department of Internal Medicine, and Department of Community Health Sciences, University of Manitoba; C.A. Hitchon, MD, MSc, Department of Internal Medicine, University of Manitoba; A. Garland, MD, MA, Department of Internal Medicine, and Department of Community Health Sciences, and Manitoba Centre for Health Policy, University of Manitoba;C.N. Bernstein, MD, Department of Internal Medicine, and IBD Clinical and Research Centre, University of Manitoba; H. Chen, MSc, Manitoba Centre for Health Policy, University of Manitoba; R. Fransoo, PhD, Department of Community Health Sciences, and Manitoba Centre for Health Policy, University of Manitoba; R.A. Marrie, MD, PhD, Department of Internal Medicine, and Department of Community Health Sciences, University of Manitoba
| |
Collapse
|
41
|
Medeiros PB, Monteiro M, Cardoso T, Campello GC. The Accuracy of Saps Ii and Sofa Score to Predict Mortality in Immunosuppressed Patients Admitted in Intensive Care. Intensive Care Med Exp 2015. [PMCID: PMC4798385 DOI: 10.1186/2197-425x-3-s1-a526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
|
42
|
Heijnen T, Wilmer A, Blockmans D, Henckaerts L. Outcome of patients with systemic diseases admitted to the medical intensive care unit of a tertiary referral hospital: a single-centre retrospective study. Scand J Rheumatol 2015; 45:146-50. [DOI: 10.3109/03009742.2015.1067329] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
43
|
Nas K, Karkucak M, Durmus B, Karatay S, Capkın E, Kaya A, Ucmak D, Akar ZA, Cevik R, Kilic E, Kilic G, Ozgocmen S. Comorbidities in patients with psoriatic arthritis: a comparison with rheumatoid arthritis and psoriasis. Int J Rheum Dis 2015; 18:873-9. [PMID: 26173043 DOI: 10.1111/1756-185x.12580] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
AIM Psoriatic arthritis (PsA) is a chronic, inflammatory disease. The purpose of this study was to examine the association between PsA and comorbid conditions. This is the first study to investigate comorbid diseases in PsA in Turkey. METHODS This study was performed under the auspices of the Anatolian Group for the Assessment in Rheumatic Diseases (ANGARD) and involved participation by six university research hospitals. Patients diagnosed with and treated for PsA on the basis of clinical, radiological and laboratory findings and expert opinion were monitored using standardized examination methods and jointly prepared forms. Clinical status, accompanying systemic diseases and surgical history were recorded. RESULTS One hundred and seventy-three patients with PsA (75 male, 98 female, mean age 41.8) and 138 patients with rheumatoid arthritis (RA) (17 male, 121 female, mean age 48.6) and 67 with psoriasis (PsO) (43 male, 24 female, mean age 36.1) were included in the study. No accompanying disease was determined in 72.8% of PsA, 50.0% of RA and 80.6% of PsO groups. In regression analysis, patients with PsA had higher risk for cataract/glaucoma surgery (odds ratio [OR] = 11.99; 95% CI 1.36-105.4, P = 0.025) compared to patients with RA, and higher risk for hypertension (HT) (OR = 4.26; 95% CI 1.27-14.23, P = 0.018) compared to the patients with PsO. CONCLUSION Patients with PsA have relatively lower frequency of comorbidities like diabetes mellitus, HT and cataract/glaucoma surgery compared to the patients with RA. The increased risk for having cataract/glaucoma surgery in RA compared to PsA may be particularly attributed to the more prevalent glucocorticoid use in RA.
Collapse
Affiliation(s)
- Kemal Nas
- Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Murat Karkucak
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Bekir Durmus
- Erenkoy Physical Medicine and Rehabilitation Hospital, Faculty of Health Sciences, Association of Public Hospitals Northern Anatolian Region of Istanbul, Istanbul, Turkey
| | - Saliha Karatay
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Gazi University, Ankara, Turkey
| | - Erhan Capkın
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Arzu Kaya
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Firat University, Elazig, Turkey
| | - Derya Ucmak
- Department of Dermatology, Faculty of Medicine, Dicle University, Diyarbakir, Turkey
| | - Zeynel Abidin Akar
- Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Dicle University, Diyarbakir, Turkey
| | - Remzi Cevik
- Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Dicle University, Diyarbakir, Turkey
| | - Erkan Kilic
- Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Gamze Kilic
- Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Salih Ozgocmen
- Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| |
Collapse
|
44
|
Brünnler T, Susewind M, Hoffmann U, Rockmann F, Ehrenstein B, Fleck M. Outcomes and Prognostic Factors in Patients with Rheumatologic Diseases Admitted to the ICU. Intern Med 2015; 54:1981-7. [PMID: 26278288 DOI: 10.2169/internalmedicine.54.4283] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To assess the outcomes in a large cohort of patients suffering from rheumatic diseases admitted to the ICU of a tertiary university medical center. METHODS A retrospective chart analysis was performed in 108 patients suffering from various rheumatic diseases and the outcomes, including morbidity and mortality, were assessed in relation to the underlying diseases, treatments and complications. RESULTS Overall, 48 patients with rheumatoid arthritis, five patients with spondyloarthritis, 14 patients with vasculitis, 30 patients with connective tissue diseases and 11 patients suffering from other rheumatologic conditions were admitted to the intensive care unit (ICU). The reasons for ICU admission included infection (30%), cardiovascular complications (22%), gastrointestinal problems (18%), endocrinological disorders (7%), neurological complications (2%) and others (3%). A total of 4% of the admitted patients required close monitoring and 14% suffered from acute exacerbation of the underlying rheumatic disease. The ICU mortality rate was 16%, whereas the overall hospital mortality rate was 20%. Fatal outcomes were related to exacerbation of the rheumatic disease in 14% of the patients, infectious complications in 46% of the patients and other reasons in 41% of the patients. An increased Apache II score, the need for mechanical ventilation, renal replacement therapy, treatment with vasopressor drugs and plasma exchange therapy were identified as risk factors for mortality. CONCLUSION The overall outcomes of critically ill patients with rheumatic diseases are impaired compared to that observed in other patient groups. However, there were no significant differences in outcomes between the different rheumatic disease groups or based on the use of immunosuppressive therapy in this study. An increased Apache II score, the need for mechanical ventilation, renal replacement therapy, treatment with vasopressor drugs and plasma exchange therapy were identified as risk factors for mortality.
Collapse
Affiliation(s)
- Tanja Brünnler
- Emergency Department, Hospital of Barmherzige Brüder, Germany
| | | | | | | | | | | |
Collapse
|
45
|
Tigen K, Sunbul M, Ozen G, Durmus E, Kivrak T, Cincin A, Ozben B, Atas H, Direskeneli H, Basaran Y. Regional myocardial dysfunction assessed by two-dimensional speckle tracking echocardiography in systemic sclerosis patients with fragmented QRS complexes. J Electrocardiol 2014; 47:677-83. [DOI: 10.1016/j.jelectrocard.2014.07.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Indexed: 01/16/2023]
|
46
|
Docking R, Mackay A, Williams C, Lewsey J, Kinsella J, Booth M. Comorbidity and Intensive Care Outcome — A Multivariable Analysis. J Intensive Care Soc 2014. [DOI: 10.1177/175114371401500306] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Decisions regarding admission to intensive care are made considering both the physiological state of the patient and the burden of comorbidity. Despite many retrospective cohort studies looking at isolated comorbidities, there has been little work to study multiple comorbidities and their effect upon intensive care outcome. In this retrospective cohort analysis, detailed comorbidity and demographic data were gathered on 1,029 patients from the West of Scotland and matched to both unit and hospital mortality at 30 days. Logistic regression was performed to investigate the factors associated with death within 30 days at both hospital and unit level. Variables with a p-value <0.25 at the univariable level were considered in a multivariable model. Variable selection for the multivariable modelling was carried out using backward selection and then replicated using forward selection to check for model stability. A modelling tool was constructed for both unit and hospital mortality at 30 days. This modelling has shown significant odds ratios for hospital death for alcoholic liver disease (OR 4.83), age (1.03), rheumatological diseases (1.93) and functional exercise tolerance prior to admission (3.08). Results from this work may inform a national prospective study to validate the modelling tool on a wider population.
Collapse
|
47
|
Solomon JJ, Fischer A. Connective Tissue Disease-Associated Interstitial Lung Disease. J Intensive Care Med 2013; 30:392-400. [DOI: 10.1177/0885066613516579] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 10/15/2013] [Indexed: 01/13/2023]
Abstract
The connective tissue diseases (CTDs) are a group of systemic disorders characterized by autoimmunity and autoimmune-mediated organ damage. The lung is a frequent target and all components of the respiratory system are at risk. Interstitial lung disease (ILD) represents a broad group of diffuse parenchymal lung injury patterns characterized by varying degrees of inflammation and fibrosis, is a common manifestation of CTD particularly common in systemic sclerosis, polymyositis/dermatomyositis, and rheumatoid arthritis, and is a leading cause of significant morbidity and mortality. The lung injury patterns of CTD-associated ILD (CTD-ILD) mirror those of idiopathic interstitial pneumonia and may arise at any time during the course of the CTD or may be the first manifestation of CTD. Patients with CTD that present with respiratory failure often present significant diagnostic dilemmas. Thorough and comprehensive assessments to exclude respiratory *infection, acute interstitial pneumonia, medication toxicity, pulmonary embolism, cardiac dysfunction, and diffuse alveolar hemorrhage are the fundamental components for the evaluation of such patients. Furthermore, patients with CTD are also at risk of acute exacerbations of underlying ILD. Acute exacerbations are manifested by subacute respiratory deterioration with worsening hypoxemia in the setting of new radiographic abnormalities. The prognosis of patients with CTD having respiratory failure is often quite poor, highlighting the need for prompt and thorough clinical assessments to determine the underlying etiology and implementation of appropriate therapeutic strategies.
Collapse
Affiliation(s)
- Joshua J. Solomon
- Department of Medicine, National Jewish Health, Denver, Colorado, USA
| | - Aryeh Fischer
- Department of Medicine, National Jewish Health, Denver, Colorado, USA
| |
Collapse
|
48
|
Befort P, Corne P, Filleron T, Jung B, Bengler C, Jonquet O, Klouche K. Prognosis and ICU outcome of systemic vasculitis. BMC Anesthesiol 2013; 13:27. [PMID: 24083831 PMCID: PMC4016298 DOI: 10.1186/1471-2253-13-27] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 09/24/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Systemic vasculitis may cause life threatening complications requiring admission to an intensive care unit (ICU). The aim of this study was to evaluate outcomes of systemic vasculitis patients admitted to the ICU and to identify prognosis factors. METHODS During a ten-year period, records of 31 adult patients with systemic vasculitis admitted to ICUs (median age: 63 y.o, sex ratio M/F: 21/10, SAPS II: 40) were reviewed including clinical and biological parameters, use of mechanical ventilation, catecholamine or/and dialysis support. Mortality was assessed and data were analyzed to identify predictive factors of outcome. RESULTS Causes of ICU admissions were active manifestation of vasculitis (n = 19), septic shock (n = 8) and miscellaneous (n = 4). Sixteen patients (52%) died in ICU. By univariate analysis, mortality was associated with higher SOFA (p = 0.006) and SAPS II (p = 0.004) scores. The need for a catecholamine support or/and a renal replacement therapy, and the occurrence of an ARDS significantly worsen the prognosis. By multivariate analysis, only SAPS II (Odd ratio: 1.16, 95% CI [1.01; 1.33]) and BVAS scores (Odd ratio: 1.16, 95% CI = [1.01; 1.34]) were predictive of mortality. CONCLUSION The mortality rate of severe vasculitis requiring an admission to ICU was high. High levels of SAPS II and BVAS scores at admission were predictive of mortality.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Kada Klouche
- Department of Intensive Care Unit, Lapeyronie University Hospital, 191 Avenue du Doyen G, Giraud, Montpellier 34090, France.
| |
Collapse
|
49
|
Konstantinov KN, Tzamaloukas A, Rubin RL. Detection of autoantibodies in a point-of-care rheumatology setting. AUTO- IMMUNITY HIGHLIGHTS 2013; 4:55-61. [PMID: 26000143 PMCID: PMC4389050 DOI: 10.1007/s13317-013-0052-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 05/02/2013] [Indexed: 11/04/2022]
Abstract
Autoimmune rheumatic diseases are common and confront society with serious medical, social, and financial burdens imposed by their debilitating nature. Many autoimmune diseases are associated with a particular set of autoantibodies, which have emerged as highly useful to define and classify disease, predict flares, or monitor efficacy of therapy. However, current practice for monitoring autoantibodies is protracted, labor-intensive, and expensive. This review provides an overview on the value of point-of-care (POC) biosensor technology in the diagnosis and management of patients with autoimmune rheumatic diseases. Real-time measurement of autoantibodies will clearly benefit the rheumatology practice in emergency and urgent care settings, where definitive diagnosis is essential for initiation of correct critical care therapy. Immediate serological information in clinic will provide considerable value for long-term patient care and an opportunity for an instant, result-deduced therapeutic action, avoiding delays and improving compliance, especially in field-based and remote areas. We describe the particular autoantibodies that are useful disease and activity markers and would, therefore, be attractive to POC applications. Already existing biosensors and platforms that show promise for autoantibody testing are summarized and comparatively evaluated. As POC assessment is gaining momentum in several areas of patient care, we propose that rheumatology is poised to benefit from this innovative and affordable technology.
Collapse
Affiliation(s)
- Konstantin N. Konstantinov
- Division of Rheumatology, Department of Internal Medicine, University of New Mexico Health Sciences Center, Mail Stop MSC10-5550, Albuquerque, NM 87131 USA
| | - Antonios Tzamaloukas
- Renal Section, Raymond G. Murphy VA Medical Center, 1501 San Pedro SE, Albuquerque, NM 87108 USA
| | - Robert L. Rubin
- Department of Molecular Genetics and Microbiology, MCS08-4660, University of New Mexico Health Sciences Center, Albuquerque, NM 87131 USA
| |
Collapse
|
50
|
Han BK, Bhatia R, Traisak P, Hunter K, Milcarek B, Schorr C, Eid H, Feinstein D, Cronin P, Kolasinski SL. Clinical presentations and outcomes of systemic lupus erythematosus patients with infection admitted to the intensive care unit. Lupus 2013; 22:690-6. [DOI: 10.1177/0961203313490240] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective The objective of this article is to investigate clinical presentations and outcomes of systemic lupus erythematosus (SLE) patients with infection admitted to the intensive care unit (ICU). Methods SLE patients with infection, SLE patients with noninfectious causes, and non-SLE patients with infection were identified from the Cooper University Hospital Project IMPACT database between 2002 and 2010. We examined demographic data, APACHE II scores, physiologic data, laboratory data, length of stay in the ICU and hospital, and mortality of the three groups. Results Twenty-five SLE patients with infection, 45 SLE patients with noninfectious causes, and 1466 non-SLE patients with infection were included in the study. SLE patients with infection had higher APACHE II scores, higher maximum temperature, higher minimum and maximum heart rate (HR), lower minimum and maximum systolic blood pressure (SBP), and longer ICU length of stay in comparison to SLE patients with noninfectious causes. There were no statistical differences in white blood cell (WBC) count. SLE patients with infection had a higher mortality compared to SLE patients with noninfectious causes. There was no difference in mortality between SLE patients with infection and non-SLE patients with infection. Conclusion SLE patients with infection in the ICU had a higher mortality and a higher APACHE II score compared to SLE patients with noninfectious causes in the ICU. Their physiologic signs including temperature, HR, and SBP were more reflective of infection than their WBC count.
Collapse
Affiliation(s)
- BK Han
- Division of Rheumatology, 2Department of Biostatistics, 3Department of Internal Medicine, Cooper Medical School of Rowan University, USA
| | - R Bhatia
- Division of Rheumatology, 2Department of Biostatistics, 3Department of Internal Medicine, Cooper Medical School of Rowan University, USA
| | - P Traisak
- Division of Rheumatology, 2Department of Biostatistics, 3Department of Internal Medicine, Cooper Medical School of Rowan University, USA
| | - K Hunter
- Division of Rheumatology, 2Department of Biostatistics, 3Department of Internal Medicine, Cooper Medical School of Rowan University, USA
| | - B Milcarek
- Division of Rheumatology, 2Department of Biostatistics, 3Department of Internal Medicine, Cooper Medical School of Rowan University, USA
| | - C Schorr
- Division of Rheumatology, 2Department of Biostatistics, 3Department of Internal Medicine, Cooper Medical School of Rowan University, USA
| | - H Eid
- Division of Rheumatology, 2Department of Biostatistics, 3Department of Internal Medicine, Cooper Medical School of Rowan University, USA
| | - D Feinstein
- Division of Rheumatology, 2Department of Biostatistics, 3Department of Internal Medicine, Cooper Medical School of Rowan University, USA
| | - P Cronin
- Division of Rheumatology, 2Department of Biostatistics, 3Department of Internal Medicine, Cooper Medical School of Rowan University, USA
| | - SL Kolasinski
- Division of Rheumatology, 2Department of Biostatistics, 3Department of Internal Medicine, Cooper Medical School of Rowan University, USA
| |
Collapse
|