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International audience; Background: The coronavirus disease 2019 (COVID-19) pandemic has had a dramatic impact on cancer diagnosis and treatment. Most patients newly diagnosed with digestive system cancer are aged 65 and over. Methods: We performed a retrospective, observational, multicentre cohort study based on prospectively collected electronic health records. All adults aged 65 or over and having been newly treated for a digestive system cancer between January 2018 until August 2020 were enroled. Results: Data on 7882 patients were analysed. The first COVID-19 lockdown period led to a 42.4% decrease in newly treated digestive system cancers, and the post-lockdown period was associated with a 17% decrease. The decrease in newly treated digestive system cancer did not differ as a function of age, sex, comorbidities, primary tumour site, and disease stage. The proportion of patients admitted to an emergency department increased during the lockdown period. We do not observe a higher 3-month mortality rate in 2020, relative to the corresponding calendar periods in 2018 and 2019. Conclusion: To avoid a decrease in newly treated cancers during future lockdown periods, access to healthcare will have to be modified. Although 3-month mortality did not increase in any of the patient subgroups, the 2020 cohort must be followed up for long-term mortality.

Neurofibromatosis 1 (NF1) is an inherited, autosomal-dominant, tumor predisposition syndrome with a birth incidence as high as 1:2000. A patient with NF1 is four to five times more likely to develop a malignancy as compared to the general population. The number of epidemiologic studies on lymphoproliferative malignancies in patients with NF1 is limited. The aim of this study was to determine the incidence rate of lymphoproliferative malignancies (lymphoma and leukemia) in NF1 patients followed in our referral center for neurofibromatoses. We used the Informatics for Integrated Biology and the Bedside (i2b2) platform to extract information from the hospital’s electronic health records. We performed a keyword search on clinical notes generated between Jan/01/2014 and May/11/2020 for patients aged 18 years or older. A total of 1507 patients with confirmed NF1 patients aged 18 years and above were identified (mean age 39.2 years; 57% women). The total number of person-years in follow-up was 57,736 (men, 24,327 years; women, 33,409 years). Mean length of follow-up was 38.3 years (median, 36 years). A total of 13 patients had a medical history of either lymphoma or leukemia, yielding an overall incidence rate of 22.5 per 100,000 (0.000225, 95% confidence interval (CI) 0.000223–0.000227). This incidence is similar to that of the general population in France (standardized incidence ratio 1.07, 95% CI 0.60–1.79). Four patients had a medical history leukemia and 9 patients had a medical history of lymphoma of which 7 had non-Hodgkin lymphoma, and 2 had Hodgkin lymphoma. Our results show that adults with NF1 do not have an increased tendency to develop lymphoproliferative malignancies, in contrast to the general increased risk of malignancy. While our results are consistent with the recent population-based study in Finland, they are in contrast with the larger population-based study in England whereby NF1 individuals were found to be 3 times more likely to develop both non-Hodgkin lymphoma and lymphocytic leukemia. Large-scale epidemiological studies based on nationwide data sets are thus needed to confirm our findings.

Neurofibromatosis 1 (NF1) is one of the most common autosomal dominant genetic disorders with a birth incidence as high as 1:2000. It is caused by mutations in the NF1 gene on chromosome 17 which encodes neurofibromin, a regulator of neuronal differentiation. While NF1 individuals are predisposed to develop benign and malignant nervous system tumors, various non-tumoral neurological conditions including multiple sclerosis (MS) have also been reported to occur more frequently in NF1. The number of epidemiologic studies on MS in NF1 individuals is very limited. The aim of this study was to determine the estimated population proportion of MS in NF1 patients followed in our Referral Centre for Neurofibromatosis using the Informatics for Integrated Biology and the Bedside (i2b2) platform to extract information from the hospital’s electronic health records. We found a total 1507 patients with confirmed NF1, aged 18 years (y) and above (mean age 39.2y, range 18-88y; 57% women). Five NF1 individuals were found to have MS, yielding an estimated population proportion of 3.3 per 1000 (0.0033, 95% Confidence Interval 0.0014–0.0077). The median age at diagnosis was 45 y (range 28–49 y). Three patients had relapsing-remitting MS and two patients had secondary progressive MS. Patients with NF1 were found to be twice more likely to develop MS than the general population in France (odds ratio 2.2), however this result was not statistically significant (95% Confidence Interval 0.91–5.29). Our results show that patients with NF1 might have a slight increased tendency to develop MS; however, due to the small sample size of our study, the results may not be sufficiently powered to detect this rare association. Large-scale epidemiological studies based on nationwide datasets are needed to confirm our findings. These findings further emphasize the need for a focused follow-up of patients with NF1, as early detection and management of MS can prevent further neurological disability.

Particulate matter with a diameter of less than 10 µm (PM 10 ) or less than 2.5 µm (PM 2.5 ) are major air pollutants poorly studies regarding psychiatric disorders. We aimed to explore the association between PM 10 and PM 2.5 air pollution peaks and the daily number of emergency visits for psychotic and mood disorders. Clinical data were collected from the Emergency department of the Centre Hospitalo-Universitaire Henri-Mondor (Créteil, France) from 2008 to 2018. Air pollution data were collected from public databases. Pollution peaks periods were defined as days for which the daily mean level of PM was above nationally predefined warning thresholds (20 µg/m 3 for PM 2.5 , and 50 µg/m 3 for PM 10 ), and the 6 following days. Multivariable analyses compared the number of daily visits for psychotic and mood disorders according to pollution peak period. After adjustment on meteorological variables, the daily number of emergency visits for psychotic disorders was significantly higher during with PM 2.5 and PM 10 air pollution peaks periods; while the number of visits for unipolar depressive disorders was higher only during PM 10 peaks periods (β=0.059, p-value=0.034). There was no significant differences concerning bipolar disorders. Differences in the effects of PM air pollution on psychotic and mood disorders should be analyzed in further studies.

Particulate matters with a diameter of less than 10 µm (PM

International audience; BackgroundPrior research suggests that psychiatric disorders could be linked to increased mortality among patients with COVID-19. However, whether all or specific psychiatric disorders are intrinsic risk factors of death in COVID-19 or whether these associations reflect the greater prevalence of medical risk factors in people with psychiatric disorders has yet to be evaluated.MethodsWe performed an observational, multicenter, retrospective cohort study to examine the association between psychiatric disorders and mortality among patients hospitalized for laboratory-confirmed COVID-19 at 36 Greater Paris University hospitals.ResultsOf 15,168 adult patients, 857 (5.7%) had an ICD-10 diagnosis of psychiatric disorder. Over a mean follow-up period of 14.6 days (SD = 17.9), 326 of 857 (38.0%) patients with a diagnosis of psychiatric disorder died compared with 1276 of 14,311 (8.9%) patients without such a diagnosis (odds ratio 6.27, 95% CI 5.40–7.28, p < .01). When adjusting for age, sex, hospital, current smoking status, and medications according to compassionate use or as part of a clinical trial, this association remained significant (adjusted odds ratio 3.27, 95% CI 2.78–3.85, p < .01). However, additional adjustments for obesity and number of medical conditions resulted in a nonsignificant association (adjusted odds ratio 1.02, 95% CI 0.84–1.23, p = .86). Exploratory analyses after the same adjustments suggested that a diagnosis of mood disorders was significantly associated with reduced mortality, which might be explained by the use of antidepressants.ConclusionsThese findings suggest that the increased risk of COVID-19–related mortality in individuals with psychiatric disorders hospitalized for COVID-19 might be explained by the greater number of medical conditions and the higher prevalence of obesity in this population and not by the underlying psychiatric disease.

The SARS-Cov2 may have impaired care trajectories, patient overall survival (OS), tumor stage at initial presentation for new colorectal cancer (CRC) cases. This study aimed at assessing those indicators before and after the beginning of the pandemic in France. In this retrospective cohort study, we collected prospectively the clinical data of the 11.4 million of patients referred to the Greater Paris University Hospitals (AP-HP). We identified new CRC cases between 1 January 2018 and 31 December 2020, and compared indicators for 2018-2019 to 2020. pTNM tumor stage was extracted from postoperative pathology reports for localized colon cancer, and metastatic status was extracted from CT-scan baseline text reports. Between 2018 and 2020, 3602 and 1083 new colon and rectal cancers were referred to the AP-HP, respectively. The 1-year OS rates reached 94%, 93% and 76% for new CRC patients undergoing a resection of the primary tumor, in 2018-2019, in 2020 without any Sars-Cov2 infection and in 2020 with a Sars-Cov2 infection, respectively (HR 3.78, 95% CI 2.1-7.1). For patients undergoing other kind of anticancer treatment, the percentages are 64%, 66% and 27% (HR 2.1, 95% CI 1.4-3.3). Tumor stage at initial presentation, emergency level of primary tumor resection, delays between the first multidisciplinary meeting and the first anticancer treatment did not differ over time. The SARS-Cov2 pandemic has been associated with less newly diagnosed CRC patients and worse 1-year OS rates attributable to the infection itself rather than to its impact on hospital care delivery or tumor stage at initial presentation.

Purpose Corynebacterium spp. (C. spp.) is commonly considered as a contaminant in respiratory specimens. No study has ever focused on its clinical relevance in the lower respiratory tract of patients admitted to the intensive care unit (ICU) and requiring mechanical ventilation. The aims were to describe the characteristics of ICU patients with a C. spp. positive deep respiratory specimen, to investigate the impact of C. spp. on the occurrence of pneumonia, and to evaluate the outcomes of these pneumonia. Methods We retrospectively included all adult patients admitted to ICU in a 1000-bed University Hospital (2007–2017) who had a C. spp. positive lower respiratory tract specimen at a significant quantitative level. We used clinical, radiological, and microbiological criteria to classify the likelihood of such pneumonia. Results Among the 31 patients included, acute respiratory failure and postoperative care after major surgery were the main reasons of admission. SAPS II was 47 [34–60]. C. spp. pneumonia was considered as probable, possible and unlikely in 10, 14, and 7 patients, respectively. Fifty-two and 94% of C. spp. strains were sensitive to amoxicillin, and vancomycin/linezolid, respectively. Seventeen patients had a complete course of antibiotic against C. spp. The overall ICU mortality was 58%. Conclusion Corynebacterium spp seems to be responsible for authentic pneumonia in mechanically ventilated patients. It should be considered as clinically relevant when predominantly present in respiratory specimen from patients suspected with pneumonia in ICU, and empirically treated.

BACKGROUND Because of its rarity, the exact incidence of and mortality from epidermal necrolysis (Stevens-Johnson syndrome/toxic epidermal necrolysis) is difficult to establish and closely depends on the size and type of the data source. OBJECTIVES To estimate the incidence of and mortality due to epidermal necrolysis in France over a 14-year period. METHODS Data from four national databases were analysed. A capture-recapture analysis was performed. RESULTS A total of 2635 incident cases of epidermal necrolysis were recorded in at least one of the four databases during the study period [males: 47·9%; median age: 52 (interquartile range 25-72) years]. On capture-recapture analysis, the estimated total number of cases was 5686, for an overall estimated annual incidence of 6·5 (95% confidence interval 4·1-8·9) cases per million inhabitants. The estimated annual incidence rates were 4·1 (0·3-7·9) cases per million inhabitants < 20 years of age, 3·9 (1·5-6·3) cases per million inhabitants aged 20-64 years and 13·7 (5·4-22·0) cases per million inhabitants ≥ 65 years of age. The estimated overall annual mortality rate from epidermal necrolysis was 0·9 (0·1-1·8) case per million inhabitants. It was 0·6 (0·1-1·5) case per million inhabitants aged 20-64 years and 2·8 (0·9-6·6) cases per million inhabitants ≥ 65 years of age (deaths in people < 20 years old were too rare to provide an accurate estimate). CONCLUSIONS The annual incidence of epidermal necrolysis is higher than the one to five cases per million inhabitants usually reported. Such estimations could be helpful in establishing appropriate healthcare plans for people with epidermal necrolysis, in particular the need for specialized care units. What's already known about this topic? Few data are available regarding incidence of and mortality from epidermal necrolysis in the general population. Experts in epidermal necrolysis have recently proposed an annual incidence of one to five cases per million individuals. The overall mortality rate is usually reported to be between 10% and 20%. What does this study add? Using a four-source capture-recapture method and data from a 14-year period (2003-16), the annual incidence of and mortality from epidermal necrolysis were estimated to be 6·5 (95% confidence interval 4·1-8·9) and 0·9 (0·1-1·8) cases per million French inhabitants, respectively. Such estimations could be helpful in establishing appropriate healthcare plans, in particular the need for specialized care units.

Background Direct detection of SARS-CoV-2 viral proteins in nasopharyngeal swabs using lateral flow immunoassays is a simple, fast and cheap approach to diagnose the infection. Aims and Methods The performance of 6 SARS-CoV-2 antigen rapid diagnostic tests has been assessed in 634 hospitalized patients or outpatients including 297 patients found to be positive for SARS-CoV-2 RNA by means of RT-PCR and 337 patients presumed to be SARS-CoV-2 RNA-negative. Results The specificity of SARS-CoV-2 RDTs was generally high (398.5%). One assay had a lower specificity of 93.2%. The overall sensitivity of the 6 RDTs was variable, from 32.3% to 61.7%. Sensitivity correlated with the delay of sampling after the onset of symptoms and the viral load estimated by the Ct value in RT-PCR. Four out of 6 RDTs tested achieved sensitivities 380% when clinical specimens were collected during the first 3 days following symptom onset or with a Ct value ≤25. Conclusions The present study shows that SARS-CoV-2 antigen can be easily and reliably detected by RDTs. These tests are easy and rapid to perform. However, the specificity and sensitivity of COVID-19 antigen RDTs may widely vary across different tests and must therefore be carefully evaluated before releasing these assays for realworld applications.

BackgroundBloodstream infections (BSIs) are frequent on veno-arterial extracorporeal membrane oxygenation (V-A ECMO). Performing routine blood cultures (BCs) may identify early paucisymptomatic BSIs. We investigated the contribution of systematic daily BCs to detect BSIs on V-A ECMO.MethodsThis was a retrospective study including all adult patients requiring V-A ECMO and surviving more than 24 h. Our protocol included routine daily BCs, from V-A ECMO insertion up to 5 days after withdrawal; other BCs were performed on-demand.ResultsOn the 150 V-A ECMO included, 2146 BCs were performed (1162 routine and 984 on-demand BCs); 190 (9%) were positive, including 68 contaminants. Fifty-one (4%) routine BCs revealed BSIs; meanwhile, 71 (7%) on-demand BCs revealed BSIs (p = 0.005). Performing routine BCs was negatively associated with BSIs diagnosis (OR 0.55, 95% CI [0.38; 0.81],p = 0.002). However, 16 (31%) BSIs diagnosed by routine BCs would have been missed by on-demand BCs. Independent variables for BSIs diagnosis after routine BCs were: V-A ECMO for cardiac graft failure (OR 2.43, 95% CI [1.20; 4.92],p = 0.013) and sampling with on-going antimicrobial therapy (OR 2.15, 95% CI [1.08; 4.27],p = 0.029) or renal replacement therapy (OR 2.05, 95% CI [1.10; 3.81],p = 0.008). Without these three conditions, only two BSIs diagnosed with routine BCs would have been missed by on-demand BCs sampling.ConclusionsAlthough routine daily BCs are less effective than on-demand BCs and expose to contamination and inappropriate antimicrobial therapy, a policy restricted to on-demand BCs would omit a significant proportion of BSIs. This argues for a tailored approach to routine daily BCs on V-A ECMO, based on risk factors for positivity.

AimsThe COVID-19 pandemic and associated lockdown may have psychiatric consequences and increase the number of psychiatric emergency consultations. This study aimed to compare the number and characteristics of emergency psychiatric consultations during the four first weeks of the lockdown in three psychiatric emergency services from Paris and its suburbs, and to compare them to the same period in 2019.MethodsThree psychiatric centers in Paris and its suburbs took part in the study. We compared the number of total psychiatric emergency consultations during the 4 first weeks of the lockdown in France to the corresponding 4 weeks in 2019. We also compared the number of consultations during these 4-week time periods in 2020 and 2019 across different diagnostic categories.ResultsIn the 4 first weeks of the lockdown in France, 553 emergency psychiatry consultations were carried out, compared to 1224 consultations during the corresponding period of 2019, representing a 54.8 % decrease. This decrease was evident across all psychiatric disorders, including anxiety (number of consultations in 2020 representing 36.1 % of 2019), mood (41.1 %), and psychotic disorders (57.3 %). The number of suicide attempts also decreased (number of suicide attempts in 2020 representing 42.6 % of 2019). In comparison to 2019, the proportion of total consultations for anxiety disorders also decreased (16.6 % vs. 20.8 %), whilst the proportion of total consultations increased for psychotic disorders (31.1 % vs. 24.1 %).ConclusionsThe total number of psychiatric emergency consultations during lockdown dramatically decreased. The psychological consequences of lockdown may be delayed, indicating that psychiatric services should be prepared for a secondary increase in emergency presentations.

Introduction Le maintien de la continuité des soins dermatologiques pendant la pandémie COVID-19 a contraint les dermatologues à utiliser téléconsultation (TC) et télé-expertise (TLX). L’objectif de ce travail était d’estimer si l’implantation de la télédermatologie (TD) pendant la pandémie pourrait (ou non) compenser l’activité ambulatoire prédite en l’absence du COVID-19. Matériel et méthodes Entre janvier 2019 et décembre 2020 l’activité présentielle, soit le nombre mensuel de consultations dermatologiques programmées (CDP) et de consultations non programmées d’urgences dermatologiques (UD) ainsi que le nombre de TC et TLX ont été recueillis au sein d’un service hospitalo-universitaire de dermatologie. Pour chacune des activités, un modèle ARIMA (modèle autorégressif et moyenne mobile) a été appliqué afin de prédire l’évolution d’une série temporelle complète (représentation de phénomènes variant dans le temps et prédiction de valeurs futures en fonction de valeurs précédentes). Pour confirmer que ces modifications étaient liées à la pandémie COVID 19, un modèle d’inférence causale a été effectué. Résultats L’impact de la pandémie COVID 19 et des confinements sur l’activité d’un service de dermatologie est illustré dans la Figure 1 et le tableau 1. Pendant le premier confinement, on observe une nette diminution de l’activité présentielle : pour les UD, le modèle ARIMA et d’inférence causale montrent respectivement une baisse de 4472 et 4635 consultations entre mars et octobre 2020 (p

Background Necrotising soft-tissue infections (NSTI) are rare, life-threatening conditions. Objectives We aimed to assess whether admitting hospital characteristics were associated with NSTI mortality. Methods We studied the French nationwide hospital discharge database (retrospective national cohort). All patients admitted in 2007-2012 with an ICD-10 code of necrotising fasciitis were eligible. We extracted data on the patients (age, sex, ICU admission, co-morbidities) and hospitals (public vs private proprietary; for public hospitals, teaching, yes/no; and number of NSTI admissions, ≥3 NSTI cases/year, yes/no). Multivariable analyses were performed to identify independent predictors of day-28 mortality and in-hospital mortality using mixed logistic regression and Cox proportional hazards models, respectively. Results We identified 1537 patients (915 males) with a median age of 60 (IQR, 48-75) years, admitted to 326 hospitals, public (82%) and admitting fewer than three NSTI cases/year (93%). Overall, 364 patients died (23·7%; 95%CI, 21·6-25·9). Patients treated in public teaching centres with ≥3NSTI cases annually had lower day-28 mortality (adjusted odds ratio [aOR], 0·68; 95%CI, 0·46-0·99; p=0·045) and in-hospital mortality rates than patients treated in local hospitals, even after adjusting for potentially relevant individual risk factors. No significant association was found between mortality and inter-hospital transfer. Conclusions Our finding highlighted an increased survival in teaching centres with high NSTI volume procedures. If confirmed in other settings, these findings reinforce the importance of expertise in early diagnosis and management of this condition. This article is protected by copyright. All rights reserved.

Introduction L’obesite est un facteur de risque connu des dermohypodermites bacteriennes non necrosantes (DHBNN) mais son impact sur la prise en charge est peu etudie. Materiel et methodes Cohorte retrospective etudiant les patients hospitalises pour DHBNN entre janvier 2013 et decembre 2016 dans un service de dermatologie hospitalo-universitaire referent. Tous les dossiers identifiables (codage informatique « erysipele ») ont ete colliges, etudies et tries. Les donnees sociodemographiques, les facteurs de risque, la prise en charge therapeutique, la duree d’hospitalisation, la recidive et les complications ont ete analyses pour la cohorte entiere, divisee en 4 sous-groupes en fonction des indices de masse corporelle (IMC). Ont ete particulierement evalues le caractere « intermediaire » (dermohypodermites bacteriennes intermediaires (DHBI)) avec presence de signes cliniques locaux de gravite (purpura, douleur intense, phlyctenes etendues) ou une evolution defavorable malgre une antibiotherapie intraveineuse par amoxicilline adaptee au poids. Une comparaison des groupes de patients ayant un IMC Resultats 197 patients avec une DHBNN ont ete inclus, 61 (31 %) dans le groupe IMC ≤ 25, 55 (28 %) dans le groupe IMC 25–30, 58 (29 %) dans le groupe IMC 30–40 et 23 (12 %) dans le groupe IMC ≥ 40. La comparaison des patients obeses et non obeses (IMC Discussion Dans cette etude, l’obesite a ete identifiee comme un facteur associe a la recidive, et l’obesite morbide comme facteur associe a une hospitalisation prolongee, a la recidive et aux formes compliquees a type de DHBI. Plusieurs etudes anterieures avaient mis en evidence l’obesite comme facteur de risque independant de DHBNN, de complication, de recidive ou d’echec d’antibioprophylaxie. Une hospitalisation d’emblee est recommandee en cas d’IMC ≥ 40. La difficulte d’adapter l’antibiotherapie et la mauvaise diffusion tissulaire justifient dans ce sous-groupe un traitement intraveineux initial et un suivi specifique.

Introduction La neurofibromatose de type 1 (NF1) est une affection genetique autosomique dominante qui touche environ une personne sur 3000. En 2007, dans notre premiere etude de mortalite, nous avions identifie 56 deces en lien avec la NF1. Les tumeurs malignes des gaines nerveuses peripheriques (TMGN) en constituaient la premiere cause, suivies par les tumeurs du systeme nerveux central et les compressions medullaires. Treize ans apres, nous rapportons les causes des deces survenus chez les patients NF1, issus de notre base de donnees. Materiel et methodes Etude descriptive retrospective portant sur les causes des deces survenus depuis notre precedente etude chez les patients NF1 suivis dans notre centre. Resultats Parmi les patients suivis, 1488 avaient un statut vital connu en 2019 et 95 etaient enregistres comme decedes depuis 2007. Parmi eux 29 etaient decedes mais la cause ou la date de deces n’etait pas connue. Concernant les 66 patients decedes avec causes identifiees, 32 etaient des hommes, et l’âge moyen au deces etait de 41 ans. 9,1 % des deces sont survenus avant l’âge de 20 ans, 42,4 % entre 20 et 40 ans, 31,8 % entre 40 et 60 ans et 16,7 % apres 60 ans. Les causes majoritaires tous âges confondus etaient les TMGN dans 43,9 % des cas, suivis par les tumeurs cerebrales (12,1 %) et les cancers du sein (7,6 %). La mortalite due aux TMGN etait precoce, 27 patients sur 29 etant decedes avant l’âge de 50 ans. Le cancer du sein est apparu parmi les causes de mortalite liees a la NF1, avec 3 deces sur 5 survenus avant l’âge de 50 ans. Apres 40 ans les AVC, les morts subites et les syndromes hemorragiques representaient entre 9 et 36 % des deces. Discussion Notre etude confirme la surmortalite par cancer au cours de la neurofibromatose 1, avec les TMGN et les tumeurs du systeme nerveux central. Emerge le cancer du sein qui a l’epoque de notre premiere etude n’etait pas identifie comme lie a NF1. Les causes vasculaires liees a la vasculopathie NF1 sont a considerer apres 40 ans.

Background Epidermal necrolysis (EN) is a rare and life-threatening condition. Objectives To assess whether admitting hospital characteristics and interhospital transfer are associated with mortality due to EN. Methods We studied the French nationwide hospital discharge database (retrospective national cohort). All patients admitted during 2012-2016 with a code for EN in the International Classification of Diseases, 10th Revision, were eligible. We extracted data on the patients (age, sex, intensive care unit admission, comorbidities) and hospitals (private proprietary vs. public, nonteaching or teaching; and number of admissions for EN as a proxy for experience). Multivariable analysis was used to identify independent predictors of in-hospital mortality with mixed logistic regression. Results We identified 991 patients (467 male; mean age 52·7 ± 23 years). They were admitted to 300 different hospitals, including teaching hospitals (25% of hospitals) for around half of the patients. Overall, 597 patients (60%) had a diagnosis of Stevens-Johnson syndrome (SJS), 171 (17%) had SJS/toxic epidermal necrolysis (TEN) overlap and 223 (23%) had TEN. In total, 109 (11%) patients died: nine (2%) with SJS, 26 (15%) with SJS/TEN overlap and 74 (33%) with TEN. The in-hospital mortality rate was lower in centres with vs. without substantial EN experience - odds ratio for one supplemental EN admission in a department 0·5 (95% confidence interval 0·3-1·0); P = 0·05 - even after adjusting for potentially relevant individual risk factors. We found no significant association between mortality and interhospital transfer. Conclusions Our findings highlight increased survival of patients with EN in centres with a high volume of EN procedures. If confirmed in other settings, these findings reinforce the importance of expertise in early diagnosis and management of this condition. What's already known about this topic? Epidermal necrolysis (EN) is a rare and life-threatening condition. At the individual level, risk factors for in-hospital mortality have been identified. Few studies have examined the association between hospital characteristics and EN mortality, with special attention to referral hospitals. What does this study add? Short-term mortality rates were lower for patients in centres with EN experience than in centres without EN experience, after adjusting for known risk factors. We found no association between interhospital transfer and survival. If confirmed in other settings, these findings support the early transfer of patients with suspected or diagnosed EN to centres with experience, where a multidisciplinary approach can be implemented by experienced healthcare professionals, to maximize short-term survival.

BACKGROUND Neurofibromas in neurofibromatosis type 1 induce aesthetic and functional morbidity. Perioperative bleeding has been reported as an obstacle to neurofibroma resections. The authors studied the requirement for blood transfusion during surgical treatment of neurofibromatosis type 1. METHODS Six hundred twenty-two procedures performed on 390 neurofibromatosis type 1 patients at the national referral center from 1995 to 2011 were analyzed in two chronologic sets of patients: set 1 (February of 1995 to September of 2007), in which only one surgeon operated; and set 2 (October of 2007 to January of 2011), in which two additional surgeons were involved. Malignant peripheral nerve sheath tumors, reconstructive procedures, and spontaneous hemorrhages were excluded from the analysis. Age, sex, preoperative hemoglobin concentration, location, length, estimated volume and histologic features of the largest neurofibroma (cumulative values for multiple neurofibromas), and procedure duration were studied as potential predictors of blood transfusion that were measured in terms of units of packed red blood cells. RESULTS Seventy reconstructive procedures, two cases of spontaneous hemorrhage, and 32 malignant peripheral nerve sheath tumor resections were excluded. Among 516 procedures (318 and 198 in sets 1 and 2, respectively), 17 (2.7 percent) required blood transfusions. The requirement for transfusion was associated with neurofibroma length in both sets, with an optimal cutoff value of 13 cm in both sets. CONCLUSIONS Contrary to the literature, the requirement for blood transfusion was found to be low (2.7 percent of the cases) during elective resection of neurofibromas in neurofibromatosis type 1. Elective resections of benign neurofibromas less than 13 cm in length were not associated with a requirement for blood transfusion. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.

International audience

Introduction L’intertrigo inter-orteils a bacille Gram-negatif (BGN), bien que non rare et souvent caracteristique cliniquement, est peu etudie. Sa prise en charge n’est pas codifiee et son evolution souvent prolongee avec des recidives frequentes. L’objectif principal de notre etude etait de decrire les caracteristiques de ce type d’intertrigo, de la population atteinte, de faire un etat des lieux de sa prise en charge, de preciser les facteurs favorisants ou associes, ainsi que l’eventuel impact de la prise en charge sur les recidives. Materiel et methodes Cette etude multicentrique, retrospective, descriptive a inclus tous les patients ayant presente un episode d’intertrigo suspect d’etre a BGN de janvier 2011 a decembre 2017 dans deux centres hospitaliers universitaires et deux centres hospitaliers generaux. Les donnees epidemiologiques, cliniques, paracliniques, therapeutiques et evolutives etaient recueillies a l’aide d’une fiche standardisee. Resultats Sur les 62 patients inclus (sexe ratio 9 : 1), 31/62 a eu plus d’un episode, 41/62 avaient une atteinte bilaterale. Les signes fonctionnels etaient domines par la douleur (55/62). Une hospitalisation etait necessaire chez 47/62. Pseudomonas aeruginosa etait trouve dans 49 des 58 prelevements realises, 16 patients ont recu une antibiotherapie specifique et 12 une antibiotherapie anti-streptococcique ou staphylococcique. Les facteurs favorisants ou associes rapportes etaient : eczema (41/62), mycose suspectee (36/62), conditions locales d’humidite notamment professionnelles (26/62), troubles vasculaires (25/62), hyperhidrose (10/62) et psoriasis (7/62). Pour 11/13 patients chez qui etaient realises des patch-tests, ceux-ci montraient une sensibilisation aux topiques utilises ou composants de chaussures. Parmi les 39 patients avec un suivi a plus de 6 mois, les 19 ayant recidive avaient tous des facteurs associes non controles alors que pour 13 des 20 sans recidive ils etaient controles. Discussion Notre etude confirme la frequence des recidives, la duree d’evolution longue, le tableau clinique caracteristique et la predominance de P. aeruginosa dans ces intertrigos. Si le retentissement fonctionnel est important, il est rarement associe a des complications infectieuses systemiques ou a distance. Les protocoles de soins varies refletent l’absence de recommandations. Nous avons mis en evidence l’association frequente de plusieurs facteurs favorisants/associes, en premier lieu l’eczema, justifiant une exploration allergologique systematique. Une fois ces facteurs favorisants/associes controles, les patients n’ont pas recidive, soulignant la necessite de leur prise en charge. Conclusion Cette etude nous a conduit a proposer une prise en charge standardisee centree sur les soins locaux, la recherche et la prise en charge des facteurs favorisants ou aggravants des intertrigos a BGN ( Fig. 1 ).

Background Early postoperative mortality after bariatric surgery has been reported in large national studies before sleeve gastrectomy (SG) was introduced as a stand-alone procedure. The aim of this study was to investigate the 90-day postoperative mortality rates after bariatric surgery in France on a nationwide basis. Methods All morbidly obese patients who underwent adjustable gastric banding (AGB), gastric bypass (GBP), or SG in France between 2007 and 2012 were included in this study. Multivariate analyses were conducted using the French National Health Service Database data to ascertain predictive factors for 90-day postoperative mortality. Results Data from 133,804 patients were analyzed. SG was performed in 36.5% of cases, GBP in 31.2%, AGB in 32.3%, and revisional surgery in 5.1%. The postoperative mortality rate (POM) for the 3 procedures was 0.12%. The rate of POM remained stable for AGB (0.01%), and it decreased from 0.25 to 0.08% and from 0.36 to 0.11% for SG and GBP, respectively. POM was greater among male patients and was associated with age, type-2 diabetes, high blood pressure, body mass index, open surgery, and hospital procedural volume. Conclusion The rate of early mortality after bariatric surgery was low, and has decreased greatly during the past few years. AGB presents a mortality rate close to nil and SG has a risk of early mortality that is about half that of GBP.

The laparoscopic approach might increase the number of cirrhotic patients with hepatocellular carcinoma (HCC) indicated for liver resection, otherwise contraindicated due to portal hypertension. The goal of this study was to confirm the safety of laparoscopic liver resection (LLR) in patients with portal hypertension. This prospective, single-center, open study (ClinicalTrials.gov ID: NCT02145013) included all consecutive cirrhotic patients who underwent LLR for HCC from 2014 to 2017. Short-term outcomes were compared between patients with and without clinically significant portal hypertension (CSPH, defined by hepatic venous pressure gradient ≥ 10 mmHg). The study population included 45 patients, comprising 27 patients (60%) in the no CSPH group and 18 patients (40%) in the CSPH group. All planned procedures could be performed. The two groups did not differ in the extent of resection, transfusion, duration of clamping, and need for conversion. Overall, the 90-day mortality and severe morbidity rates were nil. Moderate morbidity was significantly higher in the CSPH group (39 vs. 4%, p = 0.01); however, the two groups did not differ in the rate of unresolved liver decompensation. Intensive care unit and hospital stays were significantly longer in the CSPH group. At 2 years, overall survival was 77% in the no CSPH group and 100% in the CSPH group (p = 0.17), and recurrence-free survival was 55% in the no CSPH group and 79% in the CSPH group (p = 0.10). LLR is safe in BCLC 0-A patients with CSPH, with no mortality and good short-term outcomes. Re-evaluation of the BCLC guidelines is needed.

International audience; BACKGROUND: Cytomegalovirus (CMV) infection and disease (CMV episodes) are global concerns after allogeneic hematopoietic stem cell transplantation (HSCT). They affect survival, both by direct and indirect effects. Due to safety issues of current anti-CMV antivirals, long-term CMV prophylaxis is poorly tolerated and the most common strategy to decrease the incidence of CMV disease is preemptive. New, less toxic, molecules are currently being assessed for CMV prophylaxis which should replace or considerably decrease the preemptive approach. The aim of this study was to assess the economic burden of CMV episodes after HSCT with a preemptive approach.METHODS: We analyzed data from 208 consecutive adults transplanted in our institution, between 2008 and 2013. Hospital resource utilization was retrieved via the linked hospital admissions and Diagnostic Related Groups for the period of conditioning to 12 months after transplant.RESULTS: CMV episodes occurred in 70 patients (34%) over the first 12 months following HSCT, after a mean of 75 days (median: 46 (7-334)). The mean total length of stay was significantly associated with the occurrence of a CMV episode (113.9 vs. 87.5 days, p = 0.0002) but was associated neither with the pre-transplant CMV serology of donors/recipients nor with survival. The mean cost of transplant was €104,016 (SD = €37,281) after 12 months. Bivariate and multivariate analyses indicated that the occurrence of >1 CMV episode increased the costs of allogeneic HSCT by 25-30% (p

Introduction Les necrolyses epidermiques (NE, incluant syndrome de Stevens–Johnson [SJS], et necrolyse epidermique toxique [NET]) sont associees a une mortalite d’environ 25 %. En l’absence de traitement specifique ayant fait la preuve de son efficacite, les soins de support sont cruciaux pour la prise en charge. L’objectif de cette etude etait de suivre la mortalite de la NE au cours du temps dans un centre de recours. Materiel et methodes Cette etude de cohorte retrospective monocentrique a inclus tous les patients hospitalises pour une NE entre le 01/01/1997 et le 31/12/2017. Pour chacun etaient recueillis : âge, sexe, antecedents, delai a l’admission, donnees cliniques [SCORTEN, pourcentage de decollement, traitement par ciclosporine (apres 2005), sejour en reanimation] et deces pendant le premier sejour hospitalier. Trois periodes etaient identifiees : (1) 1997–2004, avant la labellisation du centre ; (2) 2005–2007, etablissement des procedures ; (3) 2008–2017, stabilite des procedures. Les caracteristiques des patients etaient comparees entre ces trois periodes a l’aide du test du Chi2 de Pearson et le test de Wilcoxon. L’evolution de la mortalite au cours du temps etait testee par une regression lineaire. Resultats Au total, 361 patients etaient inclus, d’âge median 46 ans (11–99 ans), avec 47 % de femmes. Sur l’ensemble de la periode, 66 (18 %) etaient decedes dont 35 (27 %) dans la periode 1, 4 (7 %) dans la periode 2 et 27 (15 %) dans la periode 3, avec une difference significative entre les periodes 1 et 3 (p = 0,012). Les caracteristiques des patients (âge, sexe, delai d’hospitalisation, decollement, SCORTEN, comorbidites, ciclosporine), et la proportion de patients avec sejour en reanimation figurent dans le Tableau 1 . Les patients de la periode 2 etaient plus jeunes et moins severes que ceux des deux autres periodes. On notait une tendance a un taux plus important de complications infectieuses dans la periode 3. La regression lineaire montrait une diminution significative du taux de mortalite au cours du temps (β : −0,0027 ± 0,0011, p = 0,025), correspondant a une baisse de 2,7 deces/100 hospitalisations/an. Discussion Notre etude montre une baisse significative de la mortalite au cours du temps malgre un profil de patients reste semblable. Le profil different des patients de la periode 2 peut correspondre a une fluctuation d’echantillonnage. En l’absence de traitement specifique (notamment la ciclosporine, JDP2017) ayant prouve son efficacite dans notre centre, la baisse de la mortalite pourrait resulter de l’optimisation des soins de support (compensation des pertes cutanees, soins locaux, prevention des infections, prise en charge specifique en reanimation) et peut-etre d’une meilleure detection et/ou d’un traitement plus precoce des complications infectieuses. Conclusion La mortalite des NE diminue au cours du temps sans traitement specifique autre que les soins de support et la prise en charge reanimatoire optimises.

Silent white matter changes (WMCs) on brain imaging are common in individuals with sickle cell disease (SCD) and are associated with cognitive deficits in children. We investigated the factors predictive of WMCs in adults with homozygous SCD and no history of neurological conditions. Patients were recruited from a cohort of adults with homozygous SCD followed up at an adult sickle cell referral center for which steady-state measurements of biological parameters and magnetic resonance imaging scans of the brain were available. WMCs were rated by consensus, on a validated age-related WMC scale. The prevalence of WMCs was 49% (95% confidence interval [CI], 39%-60%) in the 83 patients without vasculopathy included. In univariable analysis, the patients who had WMCs were more likely to be older (P = .003) and to have hypertension (P = .02), a lower mean corpuscular volume (P = .005), a lower corpuscular hemoglobin concentration (P = .008), and a lower fetal hemoglobin percentage (%HbF) (P = .003). In multivariable analysis, only a lower %HbF remained associated with the presence of WMCs (odds ratio [OR] per 1% increase in %HbF, 0.84; 95% CI, 0.72-0.97; P = .021). %HbF was also associated with WMC burden (P for trend = .007). Multivariable ordinal logistic regression showed an inverse relationship between WMC burden (age-related WMC score divided into 4 strata) and HbF level (OR for 1% increase in %HbF, 0.89; 95% CI, 0.79-0.99; P = .039). Our study suggests that HbF may protect against silent WMCs, decreasing the likelihood of WMCs being present and their severity. It may therefore be beneficial to increase HbF levels in patients with WMCs.

We previously reported that chronic heart failure (CHF) treatments reduce the duration of hospitalisation, even in elderly patients. The present study aimed to determine whether CHF treatment also provides long-term benefits in terms of reduced mortality at 8 years.A cohort of 281 patients who were admitted to a French teaching hospital with a main diagnosis of CHF were followed through the health insurance databases for 1 year and through the national mortality database for 8 years.Diuretics (236 patients, 84 %) and angiotensin-converting enzyme (ACE) inhibitors (193 patients, 69 %) were the most-frequently prescribed medications. The median duration of survival was 46 months. Mortality rates were significantly lower for patients administered beta-blockers (59 %) and statins (56 %) than for patients not exposed to these drugs (82 %, p 0.001 and 78 %, p = 0.001 respectively). No significant differences in mortality were observed for spironolactone, diuretics or ACE inhibitors. After adjustment, beta-blocker treatment remained associated with a significantly lower risk of mortality (hazard ratio, HR = 0.54 [0.34-0.84]). After adjustment, the use of two or three CHF drugs was associated with longer survival (HR = 0.53 [0.36-0.77]) than the use of zero or one CHF drug. Statins were also associated with longer survival after adjustment (HR = 0.53 [0.31-0.89]). In patients 75 years of age or older (n = 73), only beta-blocker treatment was associated with a significantly lower risk of mortality (HR = 0.31 [0.16-0.63]) in multivariate analysis.The use of beta-blockers was associated with better survival rates. The use of statins was also associated with better survival at 8 years. Randomised controlled trials are required to confirm these observations.

Background Among 18 face transplantations (FTs) performed worldwide, seven were performed at the Henri Mondor Hospital, Paris, France. Their feasibility and risk-benefit ratios have been reported, whereas this study analyzed the costs of FT for our first five patients. Materials and Methods The first five FT patients transplanted at the Henri Mondor Hospital presented disfigurements due to neurofibromatosis, severe burns, or ballistic trauma and had no relevant comorbidity. All were socially isolated and unemployed. We analyzed the costs of preoperative investigations, operative procedures, and hospitalization for each patient. A public research program (PHRC) financed the procedures, and the clinical research department refunded each FT’s cost. To allow comparisons between health care systems, the cost of FT was compared with the mean costs of heart, liver, and kidney transplantations performed at the same institution. Results If all the five patients survived the FT procedure, one patient died during subsequent revisions procedures for sepsis. The overall costs for the operation and its subsequent hospitalization for each patient ranged from (20AC)103,108 to (20AC)170,071, depending on the transplant required, the technical pitfalls, the outcomes, and mainly postoperative intensive cares. Conclusions In our institution, the transplantation of a face led to higher costs than heart or any other solid organ and represented twice the costs faced for a liver transplantation. FT is currently performed in a research setting, and cost might decrease with teams’ experiences, which may shorten postoperative intensive care and overall hospital stays.

Introduction Les dermo-hypodermites-fasciites necrosantes (DHBN-FN) sont des infections rares et graves (25–30 % de mortalite). Le delai a la 1re chirurgie est un des facteurs de risque de mortalite. Ce delai depend des delais au diagnostic, a la decision chirurgicale et a l’acces au bloc operatoire. Ces elements pourraient, selon notre hypothese, etre facilites dans les centres de recours tertiaires. L’objectif de cette etude etait d’evaluer l’impact d’une prise en charge ou non en centre tertiaire sur la mortalite des DHBN-FN en France. Materiel et methodes Les bases nationales du PMSI ont ete interroges pour la periode 2007–2012 afin d’inclure l’ensemble des sejours dont le diagnostic principal comportait le code « fasciite necrosante ». Les donnees recueillies retrospectivement etaient : (1) les caracteristiques sociodemographiques et comorbidites, un sejour en reanimation, le transfert interhospitalier et le deces et (2) le type de structure (public/prive) et « l’experience » dans le domaine (≥3 DHBN-FN/an, Resultats 1506 patients ont ete identifies, âges de 60,3 ans ( ± 19) (609 femmes), pris en charge dans 325 centres (82 % public, 17 % hospitalo-universitaires dont 36 % prenant en charge ≥ 3 DHBN-FN/an). 197 (13 %) patients avait ete transferes, 1025 (68 %) avaient fait un sejour en reanimation, 271 etaient decedes a J28. La figure montre la repartition des structures hospitalieres prenant en charge des DHBN-FN en fonction du nombre de patients et du taux de mortalite. Concernant la mortalite a J28, apres ajustement sur les facteurs de confusion (âge, sexe, comorbidites, sejour en reanimation), les hopitaux universitaires prenant en charge ≥ 3 DHBN-FN/an etaient associes a une moindre mortalite (OR = 0,7, IC95 % [0,5 ; 0,9] ; p = 0,04) en comparaison aux hopitaux publics (universitaires ou non) prenant en charge Discussion Une moindre mortalite a court et moyen terme des patients DHBN-FN etait observee dans les centres tertiaires prenant en charge plus de 3DHBN-FN/an. De plus, le transfert inter-hospitalier n’etait pas associe a un sur-risque de mortalite, contrairement a certaines etudes anterieures n’ayant pas pris en compte les caracteristiques des structures recevant les patients transferes, et notamment l’experience pour ce type de prise en charge. Conclusion Les transferts vers les centres tertiaires des DHBN-FN diagnostiquees ou suspectees devraient etre facilites au sein d’une zone geographique definie afin d’esperer une amelioration de la mortalite.

Introduction Chaque medecin a l’obligation de declarer tout effet indesirable medicamenteux a la pharmacovigilance. On ne sait pas si les cas de syndrome de Lyell (NET)/Stevens–Johnson (SJS), effet indesirable medicamenteux severe par excellence, sont systematiquement declares a la pharmacovigilance (PV). Materiel et methodes Dans cette etude retrospective nationale, nous avons estime la proportion de non-declaration a la PV des cas de SJS/NET issus de 3 sources : RegiSCAR (2003–2012/2015–2016), CepiDC (base de recueil de mortalite, 2003–2014) et PMSI (2008–2016). Nous avons recueilli de maniere standardisee les donnees demographiques et cliniques (âge, sexe, diagnostic, annee de survenue, region, deces) et en avons analyse leur association a la non-declaration a la PV (regressions logistiques multivariees). Resultats La non-declaration a la PV concernait 30,7 % des cas de RegiSCAR, 69 % des cas du CepiDC et 71,2 % des cas du PMSI (76 % apres exclusion des cas PMSI egalement enregistres dans RegiSCAR). Les facteurs associes a la non-declaration variaient en fonction des bases de donnees. Pour le PMSI, la non-declaration diminuait avec l’âge des patients (odd ratio [OR] : 0,95 [0,91–0,99], p = 0,02) et concernait plus les hommes que les femmes (OR : 0,78 [0,62–0,97], p = 0,03). Pour RegiSCAR, seule l’annee d’hospitalisation etait associee a la non-declaration qui augmentait au cours du temps (OR : 1,12 [1,06–1,20], p Discussion Notre etude montre pour la premiere fois une proportion tres importante de sous declaration a la PV des cas nationaux de SJS/TEN, y compris ceux ayant conduit au deces du patient. En France, il a ete montre que moins de 5 % des effets indesirables medicamenteux etaient rapportes a la PV, que ces effets indesirables soient severes ou non. Bien que largement insuffisantes, les proportions de declaration trouvees dans notre etude sont donc bien superieures a celles rapportees precedemment. Ceci peut probablement s’expliquer par la gravite du tableau clinique des SJS/NET et par son caractere emblematique. La proportion superieure de cas declares issus de RegiSCAR s’explique probablement par une meilleure sensibilisation des equipes hospitalieres specialisees dans la prise en charge de ces toxidermies graves et l’implication de personnes ressources collectant les cas permettant ainsi l’optimisation de la collaboration avec la PV. Conclusion Beaucoup reste a faire pour ameliorer la declaration systematique des effets indesirables medicamenteux a la pharmacovigilance. En plus de contribuer a la connaissance epidemiologique des SJS/TEN, RegiSCAR a egalement permis l’enrichissement de la pharmacovigilance concernant ces toxidermies graves.

Revised response criteria for aggressive lymphomas have been proposed (Cheson, J Clin Oncol, 2007) stressing the role of (18)fluorodeoxyglucose-positron emission tomography (PET) in posttreatment evaluation. The value of PET after four cycles compared with the International Workshop Criteria (IWC) remains to be established.In all, 103 patients with untreated diffuse large B-cell lymphoma were prospectively enrolled to evaluate the prognostic impact of PET after two and four cycles.Median age was 53 years (19-79), 68% male. The International Prognostic Index was low=22%, low-intermediate=19%, intermediate-high=33% and high risk=26%. Treatment consisted of cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP) (30%) or dose-intensified CHOP (70%), with rituximab (49%) or without (51%). Ninety-nine patients were evaluated by PET and IWC at four cycles: 77 (78%) had a negative PET, while 22 (22%) remained positive. The 5-year event-free survival (EFS) was 36% for patients with a positive PET versus 80% with a negative examination, whatever the response [complete response (CR) versus partial response (PR)] according to IWC (P0.0001). Positive PET patients had a 5-year EFS of 58% if in CR/CR unconfirmed by IWC and 0% if not (P0.0001). The same observations could be made in patients treated with and without rituximab.The integration of PET in treatment evaluation offers a powerful tool to predict outcome.

Background and Objectives Diffuse large B-cell lymphomas (DLBCL) have a variable outcome, and powerful methods of prognostication are needed in order to choose the best treatment for each patient. Immunophenotypic classification of the tumor as germinal center (GC) or non-germinal center-like (nGC) and early response evaluation with 18fluorodeoxyglucose positron emission tomography (18FDG-PET) scanning have been correlated with survival in DLBCL but the two methods have never been evaluated simultaneously in the same patient population. Our aim was to investigate their respective prognostic values in the same series of patients.Design and Methods We investigated the expression of CD10, Bcl-6, and MUM1 in 81 patients with DLBCL evaluated early with 18FDG-PET. The tumors were classified as GC or nGC using the algorithm of Hans et al. The results of both methods were correlated with the patients’ characteristics and survival.Results CD10 was positive in 27/76 (36%), Bcl-6 in 43/74 (58%), and MUM1 in 33/73 (45%) interpretable cases. Thirty-eight (51%) were in the GC group, and 36 (49%) in the nGC group. With a median follow-up of 33 months, estimated 3-year event-free survival (EFS) of the whole population was 67%. There was no influence of GC/nGC phenotype on survival. Three-year EFS was 46% in the early PET-positive group versus 80% in the PET-negative group (p=0.0003).Interpretation and Conclusions The prognostic value of GC/nGC phenotype is not confirmed in this heterogeneous series, whereas early PET findings are confirmed to be a powerful predictor of outcome. The impact of treatment decisions based on early PET results should be evaluated.

Adjustable gastric banding (AGB) has been a very common bariatric procedure, but long-term AGB related complications have led to an increased number of second procedures. Sleeve gastrectomy (SG) is one option and can be done as a 1- or 2-step procedure.To compare the 1-step and 2-step approachs of conversion of AGB to SG with respect to postoperative mortality and morbidity.Nationwide study, France.All morbidly obese patients who underwent AGB followed by SG in France between 2007 and 2012 were included. Multivariate analyses were conducted using the French National Health Service Database data to ascertain predictive factors for 90-day postoperative mortality and morbidity.There were 2061 and 1296 patients in the 1-step and 2-step conversion groups, respectively. The readmission rate was 22.8% and 16.5% in the 1- and 2-step groups, respectively (P.001). More patients required an intensive care unit stay in the 1-step group (11.7 % versus 6.7%; P.001). The 90-day mortality was .1%, with no difference between the 2 groups (1% versus .08%). The complication rate was 14.7% (1-step 15.9% versus 2-step 12.7%; P = .009). The timing of AGB removal (P = .02), patient age 50-60 years (P = .004), hypertension (P = .01), surgical approach (P = .002), and hospital status (P = .015) were significantly associated with the complication rate.This study indicates that the 2-step conversion of failed AGB to SG results in a significantly reduced rate of postoperative staple line leaks, gastric tube stricture, respiratory complication, and need for intensive care unit stay.

Resume La performance des services de reanimation a pu etre evaluee par le « Standardized Mortality Ratio » (SMR) en comparant la mortalite hospitaliere observee a la mortalite predite par l'IGSII. Objectifs Le Programme hospitalier de recherche clinique (PHRC) multicentrique national « Performance en Reanimation » a eu pour objectif d'evaluer l'exhaustivite des informations contenues dans le « Programme de Medicalisation des Systemes d'Information » (PMSI), de comparer la valeur du SMR des services de reanimation participants et de degager les facteurs explicatifs des differences constatees. Type d'etude Etude retrospective multicentrique. Donnees et methodes Extraction et analyse des resumes standardises anonymises des services de reanimation volontaires. Resultats Cent six services (reanimation chirurgicale : 18, medicale : 34 et polyvalente : 54) ont participe a l'etude. Le SMR des 87 099 sejours comportant un IGSII present ou non nul s'elevait a 0,84 [0,82–0,85]. La repartition des SMR des services s'etendait de 0,41 a 1,55. Dix services avaient un SMR superieur a 0,85 suggerant une performance moindre et presentaient une proportion plus elevee de sejours comportant une defaillance cardiocirculatoire. Les services dont la performance etait meilleure (SMR Conclusion La prise en compte de ces resultats parait indispensable a toute comparaison des services de reanimation fondee sur le seul SMR, notamment lorsque les services etudies accueillent un grand nombre d'intoxications medicamenteuses.

Constant flow insufflation of oxygen (CFIO) through a Boussignac multichannel endotracheal tube has been reported to be an efficient ventilatory method during chest massage for cardiac arrest.Patients resuscitated for out-of-hospital cardiac arrest were randomly assigned to standard endotracheal intubation and mechanical ventilation (MV; n =457) or use of CFIO at a flow rate of 15 l/min (n=487). Continuous chest compressions were similar in the two groups. Pulse oximetry level was recorded every 5[Symbol: see text]min. Outcome of initial resuscitation, hospital admission, complications, and discharge from the intensive care unit (ICU) were analyzed. The randomization scheme was changed during the study, but the in-depth analysis was performed only on the first cohort of 341 patients with CFIO and 355 with MV, because of randomization problems in the second part.No difference in outcome was noted regarding return to spontaneous circulation (CFIO 21%, MV 20%), hospital admission (CFIO 17%, MV 16%), or ICU discharge (CFIO 2.4%, MV 2.3%). The level of detectable pulse saturation and the proportion of patients with saturation above 70% were higher with CFIO. Ten patients with MV but only one with CFIO had rib fractures.CFIO is a simplified alternative to MV, with favorable effects regarding oxygenation and fewer complications, as observed in this group of patients with desperate prognosis.

Resume Introduction. – Les departements d’information medicale (DIM) sont charges de la collecte et de la transmission des donnees des sejours hospitaliers (resumes d’unites medicales — RUM —) aux tutelles sous forme d’un resume de sejour anonymise (RSA). Ces donnees, agregees en groupes homogenes de malades (GHM), sont utilisees pour decrire l’activite des hopitaux et determiner l’allocation des ressources budgetaires. Le but de notre travail a ete d’evaluer l’exhaustivite du contenu des RUM de reanimation adresses aux DIM. Methodes. – La collection des RUM (annees 1998 et 1999) des services de reanimation francais participant au projet a ete realisee a l’aide d’un logiciel d’extraction specifique confie a leur DIM respectif. L’analyse des donnees recueillies a permis d’evaluer le taux d’exhaustivite des donnees transmises aux DIM, notamment l’indice de gravite simplifie IGS II, les actes de reanimation codes selon le champ Omega de la classification des actes medicaux (CdAM), le diagnostic principal et les diagnostics associes saisis. Resultats. – Cent-six services ont participe volontairement a l’etude. Au total, 107 652 sejours ont ete inclus. L’âge et l’IGS II moyen des patients etudies etaient 55 ± 21 ans et 35 ± 21 ans. Les durees moyennes de sejours en reanimation et hospitalier etaient respectivement 6,2 ± 12,4 et 16,1 ± 21,6 jours. Les taux de mortalite de l’ensemble des sejours en reanimation et hospitalier etaient de 15 et 19 %. L’IGS II et les actes Omega etaient retrouves pour 81 et 80 % des sejours. L’IGS II et/ou les actes Omega etaient calcules ou codes dans respectivement 94 (100/106) et 96 % (102/106) des services. Le nombre moyen d’actes Omega etait de 4,3 ± 3,9. Cependant, seulement 5 % (5/106) des services avaient un IGS II saisi pour chaque sejour. De meme, 53 % (56/106) des services ne codaient en moyenne que cinq actes Omega ou moins par sejour. Tous les sejours avaient un diagnostic principal (par definition) et le nombre moyen de diagnostics associes etait de 3,5 ± 3,8 ; 80 % (86/106) des services ne codent en moyenne que cinq diagnostics associes ou moins par sejour. Conclusion. – Ces resultats ont montre que l’exhaustivite des donnees transmises aux DIM et donc aux tutelles, en ce qui concerne l’IGS II, les actes de reanimation, la lourdeur des traitements et les diagnostics n’etait pas satisfaisante dans cette base de donnees nationale. L’activite des services de reanimation risque d’etre sous-estimee surtout si l’IGS II et certains actes Omega reperes comme « marqueurs » d’une prise en charge lourde de reanimation seront pris en compte a l’avenir.

The goal of the study was to assess whether endothelin-1 levels are increased in tissue and plasma in free flaps. To assess this hypothesis, blood samples were taken from the general circulation before and after reperfusion and from the flap after reperfusion in 20 patients undergoing breast reconstruction with free transverse rectus abdominis musculocutaneous or deep inferior epigastric perforator flaps. Tissue samples were also taken from the flap before and after the period of ischemia. Peripheral blood samples of 10 ml each were taken before the vessels were clamped and at 10 minutes and 1 hour after the flap was recharged. The flap vein was catheterized with a smooth catheter to avoid endothelial trauma, and ischemic blood from the flap was obtained immediately after the artery was unclamped and 10 minutes later. Two skin samples of 2 cm each were taken: one after dissection of the flap before division of the vessels and one after reanastomosis of the veins (one or two veins). Statistical analyses were performed with the (nonparametric) Wilcoxon signed rank test. Flap ischemia time, from vessel division to the completion of the arterial anastomosis, ranged from 35 to 120 minutes (mean, 48 minutes). The plasma endothelin-1 level extracted from the flap was 4.34 +/- 0.85 pg/ml, significantly higher than baseline, 3.87 +/- 0.81 pg/ml (p0.0001). There was a small increase, 4.5 +/- 1.03 pg/ml (p = NS), 10 minutes after reperfusion. The peripheral level after venous anastomosis was 3.78 +/- 0.79 pg/ml, not significantly different from the peripheral plasma level, before the flap was raised. The peripheral plasma level 1 hour after reperfusion was 3.83 +/- 0.8 pg/ml, with no difference from baseline. The tissue level of endothelin-1 before clamping was 3.8 +/- 0.8 pg/mg and in postischemic tissue, 5.2 +/- 0.6 pg/mg, a statistically significant increase. The authors concluded that endothelin-1 levels are elevated in free flaps. This could be an explanation for vasospasm and may lead to therapy directed against the no-reflow phenomenon.

Due to the nephrotoxicity of cyclosporin A (CsA), its benefit on long-term graft survival remains controversial, especially in low-risk patients. Here we report the 12-year results of a calcineurin-inhibitor-free regimen. One hundred and seventeen low-risk kidney recipients were prospectively randomized to maintenance therapy with either a combination of azathioprine and prednisone (group NoCsA, n=58), or with cyclosporine, azathioprine, and prednisone (group CsA, n=59). Both groups received induction therapy with anti-lymphocyte globulins (ALG). Twelve-year patient survival was 75% and 82.5% in the CsA and NoCsA groups, respectively [ P= not significant (NS)]. Twelve-year graft survival was 59% and 56% ( P=NS) in the CsA and NoCsA groups, respectively (NS). Transplant rejection rates were similar in both groups. Mean serum creatinine levels after 10 years were 161 and 136 micromol/l in the CsA and NoCsA groups, respectively. Rejection-free patients of the CsA group had poorer renal function (168 micromol/l) than those of the NoCsA group (121 micromol/l; P=0.0060). We concluded that a 12-year graft survival of 56% and a graft half-life of 15 years can be achieved without the primary use of a calcineurin inhibitor in low-risk patients receiving ALG. Patients treated with CsA had poorer graft function at 12 years.

3520 Background: Curative surgery is the best therapy of CRC and recurrences. We assessed whether adding semi-annual PET-CT to the usual surveillance would be cost-effective in high risk recurrent CRC patients. Methods: CRC patients (stage II tumor perforated, stages III and IV) in remission after curative surgery were randomly assigned (1:1) to trimester usual surveillance (control) or usual surveillance + semi-annual course PET-CT (intervention) for a 3-yr follow up period. Every 3 months, multidisciplinary committee decided about recurrence by yes/no/doubtful. If yes, curative surgery alone (when relevant), or chemotherapy alone (unresecable recurrence) were conducted; additional exams could be performed if doubtful. Primary composite endpoint (failure) comprised unresectable recurrence & death. The economic assessments according to standards (CHEERS) were performed and costs were compared between groups. Statistical tests for calculation of the relative risk (RR) were used and survival was analyzed using Kaplan-Meier method, Log-Rang test and Cox models. Results: Baseline characteristics of 239 patients (120/119) enrolled in 12 centers were balanced. The failure rate was 29.2% (31 unresectable recurrences & 4 deaths) and 23.5% (27 & 1) in Interventional vs Control, respectively with no significant difference (RR = 1.24, 95% CI: 0.81-1.90; P = .32). Similar results were observed in multivariate analysis (Cox models) adjusted for stage and tumor differentiation (HR = 1.33, 95% CI: 0.8-2.19, P = .27). Period until the unresectable recurrence was significantly shorter in Interventional (median = 7; IQR: 3-20 months) than in Control group (14.3; 7.3-27; P= 0.016). This was consistent with lower elevation (median; IQR) of tumour marker in interventional (3.8; 2.8-19) than in control group (10; 5.2-28.6) at the first recurrence time as compared to the baseline (p = 0.007). Overall (mean; SD) cost (euros)/patient was higher in the PET-Scan (9385; 11658) than in the control group (7027; 7656). Conclusions: Although recurrences were detected earlier in PET-CT group, the strategy was less effective, more expensive. This exam should not be advised routinely. Clinical trial information: NCT 00624260.

Summary Background Hydroxyethylstarch used for volume restoration in brain-dead kidney donors has been associated with impaired kidney function in the transplant recipients. We undertook a multicentre randomised study to assess the frequency of acute renal failure (ARF) in patients with severe sepsis or septic shock treated with hydroxyethylstarch or gelatin. Methods Adults with severe sepsis or septic shock were enrolled prospectively in three intensive-care units in France. They were randomly assigned 6% hydroxyethylstarch (200 kDa, 0·60–0·66 substitution) or 3% fluid-modified gelatin. The primary endpoint was ARF (a two-fold increase in serum creatinine from baseline or need for renal replacement therapy). Analyses were by intention to treat. Findings 129 patients were enrolled over 18 months. Severity of illness and serum creatinine (median 143 [IQR 88–203] vs 114 [91–175] μmol/L) were similar at baseline in the hydroxyethylstarch and gelatin groups. The frequencies of ARF (27/65 [42%] vs 15/64 [23%], p=0·028) and oliguria (35/62 [56%] vs 23/63 [37%], p=0·025) and the peak serum creatinine concentration (225 [130–339] vs 169 [106–273] mol/L, p=0·04) were significantly higher in the hydroxyethylstarch group than in the gelatin group. In a multivariate analysis, risk factors for acute renal failure included mechanical ventilation (odds ratio 4·02 [95% CI 1·37–11·8], p=0·013) and use of hydroxyethylstarch (2·57 [1·13–5·83], p=0·026). Interpretation The use of this preparation of hydroxyethylstarch as a plasma-volume expander is an independent risk factor for ARF in patients with severe sepsis or septic shock.

International audience; ABSTRACT: INTRODUCTION: To identify risk factors for early (< three days) intensive care unit (ICU) admission of patients hospitalised with community-acquired pneumonia (CAP) and not requiring immediate ICU admission, and to stratify the risk of ICU admission on days 1 to 3. METHODS: Using the original data from four North American and European prospective multicentre cohort studies of patients with CAP, we derived and validated a prediction rule for ICU admission on days 1 to 3 of emergency department (ED) presentation, for patients presenting with no obvious reason for immediate ICU admission (not requiring immediate respiratory or circulatory support). RESULTS: A total of 6560 patients were included (4593 and 1967 in the derivation and validation cohort, respectively), 303 (4.6%) of whom were admitted to an ICU on days 1 to 3. The Risk of Early Admission to ICU index (REA-ICU index) comprised 11 criteria independently associated with ICU admission: male gender, age younger than 80 years, comorbid conditions, respiratory rate of 30 breaths/minute or higher, heart rate of 125 beats/minute or higher, multilobar infiltrate or pleural effusion, white blood cell count less than 3 or 20 G/L or above, hypoxaemia (oxygen saturation < 90% or arterial partial pressure of oxygen (PaO2) < 60 mmHg), blood urea nitrogen of 11 mmol/L or higher, pH less than 7.35 and sodium less than 130 mEq/L. The REA-ICU index stratified patients into four risk classes with a risk of ICU admission on days 1 to 3 ranging from 0.7 to 31%. The area under the curve was 0.81 (95% confidence interval (CI) = 0.78 to 0.83) in the overall population. CONCLUSIONS: The REA-ICU index accurately stratifies the risk of ICU admission on days 1 to 3 for patients presenting to the ED with CAP and no obvious indication for immediate ICU admission and therefore may assist orientation decisions.

OBJECTIVES The aim of this study was to measure the impact on antibiotic use of a computer-generated alert prompting post-prescription review and direct counselling in hospital wards. METHODS A computer-generated alert on new prescriptions of 15 antibiotics was reviewed weekly by an infectious disease physician for 41 weeks. During the first 6 months of the study, criteria selected for potential intervention were: (i) a planned duration of treatment of > or =10 days; (ii) discordance between the spectrum of the prescribed antibiotic and available microbiological results; or (iii) prescriptions of broad-spectrum beta-lactams, fluoroquinolones, glycopeptides or linezolid. During the following 5 months, the alert was restricted to any prescription of the 15 antibiotics in the 9 wards where overall antibiotic use had not decreased in the past year. RESULTS We analysed 2385 prescriptions, 932 (39%) of which generated an alert for potential intervention. Among the latter, 482 (51.7%) prescriptions prompted direct counselling, mainly for shortening the planned duration of therapy (18.9%), withdrawing antibiotics (16.2%) or streamlining therapy (15.5%). The attending physicians' compliance with the recommendations was 80%. The overall median (interquartile range) days of therapy prescribed by the attending physicians was reduced from an initial duration of 8 (7-14) to 7 (6-11) days (P < 0.0001), resulting in 26.5% less antibiotic days prescribed. The time required for the intervention was 6 h per week. CONCLUSIONS This computer-prompted post-prescription review led physicians to modify one half of the antibiotic courses initially prescribed and was well accepted by the majority, although they had not requested counselling.

Purposes To identify bedside variables that aid in diagnosis of acute coronary syndrome (ACS) and might facilitate rapid triage of patients aged ≥65 years. Basic Procedures Prospective, observational study of consecutive patients aged ≥65 years with suspicion of ACS presenting to our emergency department (ED). Patients' medical characteristics were collected at baseline and during a 1-month follow-up period. We identified variables independently associated with ACS by multivariate analyses and bootstrapping techniques. Main Findings Among 399 patients, 124 (31.1%) received a diagnosis of ACS (61 acute myocardial infarction, 63 unstable angina). We surveyed multiple clinical and ECG variables to develop a predictive model which included the following variables: male sex, history of coronary artery disease, typical chest pain, dyspnea, epigastric pain, pathological Q-wave, ST-segment elevation (area under the receiver operating characteristic curve (AUC) 0.79, 95% confidence interval 0.71 to 0.82). With the addition of cardiac troponin I to the model the AUC increased to 0.83 (0.79 to 0.88). We used these findings to create the Heart Attack Risk for aged Patient (HARP) scale. Our data suggest that patients with a low HARP score might be safely managed without further testing. Principal Conclusions A model based on variables easily available at ED presentation from history, physical examination, and electrocardiography, can help ED physicians to identify seniors at very low risk of ACS.