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Search Results: 1 - 10 of 423 matches for " Elie Azoulay "
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Preventing acute renal failure is crucial during acute tumor lysis syndrome
Darmon Michael,Thiery Guillaume,Azoulay Elie
Indian Journal of Critical Care Medicine , 2007,
Abstract: Tumour Lysis syndrome (TLS) is characterized by the massive destruction of tumoral cells and the release in the extracellular space of their content. While TLS may occur spontaneously before treatment, it usually develops shortly after the initiation of cytotoxic chemotherapy. These metabolites can overwhelm the homeostatic mechanisms and cause hyperuricemia, hyperkalemia, hyperphosphatemia and hypocalcemia. Moreover, TLS may lead to an acute renal failure (ARF). In addition to the hospital mortality induced by the acute renal failure itself, development of an ARF may preclude optimal cancer treatment. Therefore, prevention of the acute renal failure during acute tumor lysis syndrome is mandatory. The objective of this review is to describe pathophysiological mechanisms leading to acute tumor lysis syndrome, clinical and biological consequences of this syndrome and to provide up-to-date guidelines to ensure prevention and prompt management of this syndrome.
Deciding intensive care unit-admission for critically ill cancer patients
Thiery Guillaume,Darmon Michael,Azoulay Elie
Indian Journal of Critical Care Medicine , 2007,
Abstract: Over the last 15 years, the management of critically ill cancer patients requiring intensive care unit admission has substantially changed. High mortality rates (75-85%) were reported 10-20 years ago in cancer patients requiring life sustaining treatments. Because of these high mortality rates, the high costs, and the moral burden for patients and their families, ICU admission of cancer patients became controversial, or even clearly discouraged by some. As a result, the reluctance of intensivists regarding cancer patients has led to frequent refusal admission in the ICU. However, prognosis of critically ill cancer patients has been improved over the past 10 years leading to an urgent need to reappraise this reluctance. In this review, the authors sought to highlight that critical care management, including mechanical ventilation and other life sustaining therapies, may benefit to cancer patients. In addition, criteria for ICU admission are discussed, with a particular emphasis to potential benefits of early ICU-admission.
Withholding and withdrawing life-sustaining treatment: the necessity of discrepancies in ethical reasoning
Frédéric Pochard, Nancy Kentish-Barnes, Elie Azoulay
Critical Care , 2008, DOI: 10.1186/cc6873
Abstract: Most studies report that factors such as proxy comprehension and symptoms of anxiety or depression are major determinants of medical end-of-life decisions [2]. A study of the general population's wishes requires the use of random sampling; but before asking the population how they would react in theoretical situations, it seems important to first evaluate their knowledge. In a survey including 8,000 residents in France [3], only 28% chose the correct definition of the intensive care unit. The population's answer reflects social need regarding an efficacious medical system of which the aim is to protect and save human life.The objective of a consensus between physicians and the general population should not be considered an ethical shield: the consensus in itself has no ethical value. As discussion permits best decision-making, the existence of discrepancies between physicians and the general population is reassuring. There is no one good or bad decision or answer because, in practice, two different but valid decisions may be taken for the same case. Determinants of a decision to forgo life-sustaining treatments are not objective, are always context related, and remain independently associated with death after adjusting for comorbidities and severity at intensive care unit admission [4]. The results of studies focusing on end-of-life intentions depend on factors such as social coverage, medical culture (including intensive care unit admission policy), evolution of medical theories, practices and techniques, clinicians' experience and values, and the psychological and relational context of patient and proxies.The authors declare that they have no competing interests.
Evaluating mortality in intensive care units: contribution of competing risks analyses
Matthieu Resche-Rigon, Elie Azoulay, Sylvie Chevret
Critical Care , 2005, DOI: 10.1186/cc3921
Abstract: We studied 203 mechanically ventilated cancer patients with acute respiratory failure consecutively admitted over a five-year period to a teaching hospital medical ICU. Among these patients, 97 died before hospital discharge. After estimating the CIF of hospital death, we used Fine and Gray models and logistic models to explain variability hospital mortality.The CIF of hospital death was 35.5% on day 14 and was 47.8% on day 60 (97/203); there were no further deaths. Univariate models, either the Fine and Gray model or the logistic model, selected the same eight variables as carrying independent information on hospital mortality at the 5% level. Results of multivariate were close, with four variables selected by both models: autologous stem cell transplantation, absence of congestive heart failure, neurological impairment, and acute respiratory distress syndrome. Two additional variables, clinically documented pneumonia and the logistic organ dysfunction, were selected by the Fine and Gray model.The Fine and Gray model appears of interest when predicting mortality in ICU patients. It is closely related to the logistic model, through direct modeling of times to death, and can be easily extended to model non-fatal outcomes.Mortality in intensive care unit (ICU) patients remains high. The estimated mean in France is about 15% for ICU mortality and 6–25% for hospital mortality after ICU discharge [1], yielding a hospital mortality rate of 20–30%, with substantial variations across studies. Reported factors associated with ICU mortality are partly conflicting. Differences in the statistical methods used to estimate mortality and to identify prognostic factors may contribute to these discrepancies. For instance, the outcome of interest could be hospital mortality, ICU mortality, or mortality at a specific time point (e.g. 14 days, 30 days, 60 days, or three months after ICU admission). Furthermore, some studies determine the prevalence of death and others determine the inc
Clinical review: Specific aspects of acute renal failure in cancer patients
Michael Darmon, Magali Ciroldi, Guillaume Thiery, Beno?t Schlemmer, Elie Azoulay
Critical Care , 2006, DOI: 10.1186/cc4907
Abstract: Acute renal failure (ARF) is a serious complication of malignancies that causes substantial morbidity and mortality. Among critically ill cancer patients (CICPs), 12% to 49% experience ARF and 9% to 32% require renal replacement therapy during their intensive care unit (ICU) stay [1-5]. The risk for ARF seems higher in CICPs than in other critically ill patients [2,6]. In critically ill patients with cancer, acute renal dysfunction usually occurs in the context of multiple organ dysfunctions and is associated with mortality rates ranging from 72% to 85% when renal replacement therapy is needed [1,2]. Moreover, the recent report of Benoit and colleagues [2] suggest that cancer patients admitted with acute kidney injury requiring renal replacement therapy may have a better prognosis if bacterial infection is present at admission. Lastly, prognosis for this population seems to be worse than the prognosis for a control cohort of critically ill patients without malignancy receiving renal replacement therapy [2]. In addition to hospital mortality, development of an ARF may preclude optimal cancer treatment by requiring a decrease in chemotherapy dosage or by contraindicating potentially curative treatment (e.g., high-dose methotrexate in patients with recently diagnosed Burkitt lymphoma) [7].Unresolved issues in this setting are similar to those in the overall population of patients with ARF, namely, the definition of ARF, the possible benefits from early dialysis, and the optimal dialysis dose.Multiple causes leading to ARF in critically ill cancer patients are often present in combination (listed in Table 1). Although some of these causes are common to the general ICU population (sepsis, shock, aminoglycosides), some are related to the malignancy itself or to its treatment. Moreover, in several studies, critically ill cancer patients have been admitted with a newly diagnosed malignancy and are therefore at risk to develop such type of malignancy-related acute kidney inj
The strategy of antibiotic use in critically ill neutropenic patients
Matthieu Legrand, Adeline Max, Beno?t Schlemmer, Elie Azoulay, Bertrand Gachot
Annals of Intensive Care , 2011, DOI: 10.1186/2110-5820-1-22
Abstract: Neutropenia is defined as a neutrophil count ≤ 500/mm3 or ≤ 1000/mm3 with a predicted decrease to ≤ 500/mm3 [1,2]. Infection remains a major complication of neutropenia, and severe sepsis and septic shock are associated with high hospital mortality [3,4]. Fever, defined as a single oral temperature ≥38.3°C or ≥38.0°C for at least 1 hour, develops in 10-50% of patients after chemotherapy for solid tumors and in more than 80% of patients with hematological malignancies [5].Urgent and appropriate antibiotic administration is mandatory to prevent further clinical deterioration, especially in critically ill patients with signs of respiratory distress or severe sepsis. Therefore, the first-line antibiotics should cover the pathogens deemed to be most likely based on the patient's characteristics, neutropenia, and local epidemiology. However, the changing epidemiology of infections, global increase in resistant strains, and need to contain healthcare costs require careful selection of antibiotics. Only 10-40% of episodes of febrile neutropenia are microbiologically documented in neutropenic patients, which hampers appropriate antibiotic spectrum adjustment in most cases [5]. This review provides an up-to-date guide to assist physicians in choosing the optimal antibiotic regimen in neutropenic patients, based on the above-mentioned considerations and on the most recent international guidelines and literature.During the 1990s, Gram-positive bacteria emerged as the leading agents responsible for infections in neutropenic patients worldwide. In adults with bloodstream infections and malignancies in the United States, the proportion of Gram-positive organisms increased from 62% in 1995 to 76% in 2000, whereas the proportion of Gram-negative infections decreased from 22% to 15% [6]. Factors that may increase the risk of Gram-positive sepsis in neutropenic patients include the widespread use of central venous catheters, introduction of prophylactic quinolone therapy, increased us
Intensive care of the cancer patient: recent achievements and remaining challenges
Elie Azoulay, Marcio Soares, Michael Darmon, Dominique Benoit, Stephen Pastores, Bekele Afessa
Annals of Intensive Care , 2011, DOI: 10.1186/2110-5820-1-5
Abstract: The number of patients living with cancer has been increasing steadily [1-3]. The ageing population, improved diagnostic tools for cancer, and decrease in cancer-related mortality have contributed to this increase. The age-adjusted invasive cancer incidence rate (95% confidence interval) in the United States is 533.8 (532.6-535.1) per 100,000 population [4]. More than 1.4 million people were projected to be diagnosed with cancer in the United States in 2009 [3]. In Europe, there were an estimated 3,191,600 cancer cases diagnosed and 1,703,000 deaths from cancer in 2006 [5]. In 2005, more than 100,000 cases of hematological malignancies were diagnosed in the United States and approximately 230,000 in Europe [4,6]. Intensive chemotherapy regimens [7] and the use of new and more targeted therapeutic drugs have resulted in high cancer cure rates. However, the treatment often leads to drug-related organ toxicities and increased susceptibility to infection [8,9]. As a consequence, intensivists are increasingly managing patients with cancer who are admitted to the intensive care unit (ICU) for organ dysfunction--chiefly respiratory failure, originating from infectious, malignant, or toxic complications [10,11]. Timely recognition and early ICU admission offer opportunities to prevent and manage life-threatening complications that are cancer-related, including tumor lysis syndrome [12], leukostasis [13], and macrophage activation syndrome [14]. Managing organ dysfunction in critically ill cancer patients requires specialized skills by the intensivist and close collaboration between the intensivist and oncologist.Critically ill cancer patients have lower survival rates compared with patients without comorbidities. However, their in-hospital mortality rates are not higher compared with critically ill patients with other comorbidities, such as heart failure, liver cirrhosis, or other serious chronic diseases [15]. Recent studies have shown that a substantial survival rate can
Ethics roundtable debate: Patients and surrogates want 'everything done' – what does 'everything' mean?
Christopher Doig, Holt Murray, Rinaldo Bellomo, Michael Kuiper, Rubens Costa, Elie Azoulay, David Crippen
Critical Care , 2006, DOI: 10.1186/cc5016
Abstract: There is always an incentive to use the newest, most interesting medication as soon as possible. There is a perception that new drugs are miracle drugs since they are formulated against the cutting edge of new developments in medicine. Frequently, patients and their families carry out Internet searches for new developments in the field of their interest, and there is much information available. Patients and their families often point out these new developments to their physicians and request they be implemented.Patients are biased to try anything in hopes of a cure. Physicians have a strong incentive to do everything reasonable for their patients, but not necessarily everything possible. If a new drug is available, even as an investigational tool, there is a temptation to use it. But the wealth of knowledge concerning these treatments differs widely between physicians and patients. We explore the viability of requests for "everything", differences between possibilities and reason and authority to request treatment and to demand it.A 70-year-old woman with a history of hypertension and deep vein thrombosis on coumadin (warfarin) is admitted to the emergency department (ED) about 1 hour after a syncopal episode and is found to have a small left-sided intracranial hemorrhage. Initially she is hemiplegic, aphasic but arousable, and with stable hemodynamics and ventilation. She is admitted to the intensive care unit (ICU) and given fresh frozen plasma and vitamin K for an international normalized ratio (INR) of 5.6. Her examination findings quickly deteriorate. Another computed tomography scan is performed an hour after admission and it is observed that the intracranial bleed is rapidly increasing in size. Repeat examination reveals no corneals, fixed pupils, and only extension of the left arm in response to painful stimulus. She is intubated and breathes over the ventilator but has no cough or gag reflex. Fresh frozen plasma is infused. Both neurosurgery and neurology c
Intravascular lymphoma presenting as a specific pulmonary embolism and acute respiratory failure: a case report
Sophie Georgin-Lavialle, Michael Darmon, Lionel Galicier, Marinos Fysekidis, Elie Azoulay
Journal of Medical Case Reports , 2009, DOI: 10.1186/1752-1947-3-7253
Abstract: A 38-year-old man was referred to our intensive care unit with acute respiratory failure and long lasting fever. Appropriate investigations failed to demonstrate any bacterial, viral, parasitic or mycobacterial infection. A chest computed tomography scan ruled out any proximal or sub-segmental pulmonary embolism but the ventilation/perfusion lung scan concluded that there was a high probability of pulmonary embolism. The cutaneous biopsy pathology diagnosed intravascular lymphoma.Intravascular lymphoma is a rare disease characterized by exclusive or predominant growth of neoplastic cells within the lumina of small blood vessels. Lung involvement seems to be common, but predominant lung presentation of this disease is rare. In our patient, urgent chemotherapy, along with adequate supportive care allowed complete recovery.Intravascular lymphoma (IVL) is an intravascular proliferation of clonal lymphocytes with little to no parenchymal involvement. The clinical presentation is highly variable, ranging from no or limited organ involvement to multiple organ failure. Therefore, the diagnosis is often difficult. Proliferation of lymphoma cells in blood vessels of parenchymal organs results in vessel obliteration and ischemia. We report a patient with an intravascular lymphoma with predominant pulmonary involvement, presenting as acute respiratory failure and a specific pulmonary embolism.In May 2005, a 38-year-old man was referred to our intensive care unit with acute respiratory failure and long lasting fever. He had an unremarkable medical history until 5 months ago when he was referred for a 15 kg weight loss and fever. Clinical examination was normal at that time. Appropriate investigations failed to demonstrate any bacterial, viral, parasitic or mycobacterial infection, including intracellular bacteria, HIV, hepatitis B virus, hepatitis C virus, tuberculosis, typhoid, syphilis, or brucellosis. Antinuclear antibodies, rheumatoid factors, and anti-neutrophil cytoplasmic
Sensitivity of the Investments of Sub-Saharan Firms to Financial Constraints  [PDF]
Elie Ngongang
Journal of Mathematical Finance (JMF) , 2013, DOI: 10.4236/jmf.2013.31A020

Investment is an important instrument of growth and competitiveness for non financial firms. However, these firms have limited financial resources (or liquidity) at their disposal. The financial constraint is defined as a conditionality to be met in order to have access to liquidity by assuming that the information held by shareholders is perfect, and that financial markets are efficient. We have attempted in this study to analyze empirically the impact of these financial constraint on the investments of Sub-Saharan manufacturing firms. We carried out an empirical analysis of a sample of 73 firms belonging to the different manufacturing sectors listed on the stock market during the period 1998-2009, and by taking inspiration from panel data methodology. The empirical tests emphasize the fact that the manufacturing firms of Sub-Saharan countries, including the smallest ones and those with which financial institutions have no close relations, witness an environment with a strong information asymmetry between borrowers and lenders. These firms are constrained in their access to external indebtedness due to the levelling-off of indebtedness. However, taking account of uncertainty could enrich the extension of this study.

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