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Funding Acknowledgements Type of funding sources: None. Background Despite the known benefits of physical activity, patients with cardiovascular disease do not practice enough nor maintain a regular physical activity for their health [1-4] . Walking is one of the easiest ways to stay physically active and can be implemented easily in everyday life [5]. Wearable physical activity monitoring devices have the potential to help increase physical activity through self-monitoring and feedback. Purpose To review randomized controlled trials using wearable physical activity monitoring device as an intervention to increase daily walking activity and improve physical capacities in cardiovascular diseases (CVD) patients. Methods Design: Systematic review and meta-analysis of randomized controlled trials (RCTs). Data Sources: PubMed, Embase, Web of Science. Eligibility criteria: Randomized controlled studies including patients over 18 years of age with CVD comparing an intervention group using a wearable physical activity monitoring device with feedback to usual care or to a control group receiving no feedback on their physical activity and reporting a change in the daily number of steps and/or a change in the distance covered in the 6-minute walking test (6MWT) or a change in peak oxygen uptake (VO2 peak). Outcomes: Primary outcome was daily number of steps, secondary ouctomes were distance covered in the 6-minute walking test (6MWT) and/or peak oxygen uptake (VO2 peak). Results Sixteen RCTs were included. The intervention of wearing a physical activity monitoring device with feedback significantly improved daily number of steps compared with controls (standardized mean difference ((SMD) 0.85; 95% CI [0.42; 1.27], p < 0.01). The effect was greater when the duration of the intervention was less than 3 months (SMD 1.0; 95% CI [0.18; 1.82], p < 0.01) than when the duration of the intervention was 3 months or longer (SMD 0.71; 95% CI [0.27; 1.16], p < 0.01) but no significant interaction was found between subgroups (p = 0.55). Six MWT distance and VO2 peak showed only small effects (SMD 0.34 (95% CI [-0.11; 0.80], p = 0.02) and SMD 0.53 (95% CI [0.03; 1.03], p = 0.07), respectively).

Aims To compare the safety and efficacy of antithrombotic regimens following transcatheter aortic valve replacement (TAVR) in patients without having an indication for chronic oral anticoagulation Methods and results We conducted a Prospero-registered systematic review and network meta-analysis of randomized controlled trials evaluating post-TAVR antithrombotic regimens up to March 2021. We estimated the relative risk and 95% confidence intervals using a fixed effect model in a frequentist pairwise and network metanalytic approach. We included 6 studies comprising of 3,777 patients with a mean weighted follow-up of 13.3 months. Single antiplatelet therapy (SAPT) was associated with a significant reduction of life-threatening, disabling, or major bleeding compared to dual antiplatelet therapy (DAPT) (Risk Ratio [RR] 0.44, 95% confidence interval [CI]: 0.28–0.69), apixaban (RR: 0.47, 95% CI 0.26–0.84) and low-dose rivaroxaban + 3-month SAPT (RR: 0.30, 95% CI: 0.16–0.57). Risk of all-cause death was significantly reduced with DAPT compared to low-dose rivaroxaban + 3-month SAPT (RR: 0.60, 95% CI: 0.41–0.88) and a consistent reduction was observed with SAPT and DAPT compared to apixaban (RR: 0.60, 95% CI: 0.31–1.16 and RR: 0.58, 95% CI: 0.32–1.04, respectively). There were no differences between the various regimens with respect to myocardial infarction and stroke. Apixaban significantly reduced the risk of pulmonary embolism, valve thrombosis and grade 3 or 4 reduced leaflet motion. Conclusion Following TAVR in patients without an indication for chronic oral anticoagulant, SAPT was associated with the lowest risk of bleeding compared to DAPT and direct oral anticoagulant-based regimens without significant ischemic offset. Funding Acknowledgement Type of funding sources: None.

In April 2020, in response to the high thrombotic risk associated with COVID-19, the GIHP and GFHT published proposals for the prevention of venous thromboembolism (VTE) and haemostasis monitoring in patients with COVID-19 [1]. In February 2021, six authors from the proposals (CT, AM, AlG, AnG, SS, YG, PA) decided to update them. This update was justified by several points: - The epidemiology of thrombotic complications has been described. - Different anticoagulation regimens have been reported, and retrospective studies have suggested that higher-than-standard prophylactic anticoagulation may be beneficial. - Initially underestimated, bleeding complications have emerged as a limitation of increased-dose anticoagulation and occur later than thrombotic events. - The first results of large-scale randomised controlled studies on increased doses of anticoagulation have been published. - Immunomodulatory therapies (corticosteroids, interleukin-6 receptor antagonists) are now widely used, but their effect on the thrombotic risk is unknown. - Despite improved survival, thrombotic complications remain a concern [2].

Le Groupe d’intérêt en hémostase périopératoire (GIHP) et le Groupe français d’études sur l’hémostase et la thrombose (GFHT), en collaboration avec la Société française d’anesthésie et de réanimation (SFAR) ont fait des propositions de gestion des agents antiplaquettaires (AAP) pour une procédure invasive programmée. Ces propositions ont été discutées et validées par vote ; toutes sauf une ont fait l’objet d’un accord fort. La gestion des AAP dépend de leur indication et de la procédure considérée. Le risque hémorragique lié à la procédure invasive peut être divisé en bas, intermédiaire ou élevé, selon la possibilité ou non de réaliser la procédure sous traitement (sous respectivement bithérapie antiplaquettaire, aspirine en monothérapie ou aucun AAP). Si une interruption des AAP est indiquée avant la procédure, une dernière prise d’aspirine, clopidogrel, ticagrélor et prasugrel 3, 5, 5 et 7 jours avant la procédure est proposée. Le risque thrombotique associé à l’interruption des AAP doit être évalué en fonction de l’indication des AAP. Il est plus élevé chez les patients traités par bithérapie pour un stent coronaire que chez ceux traités par monothérapie pour une prévention cardiovasculaire, un antécédent d’accident vasculaire cérébral ischémique ou une artériopathie oblitérante des membres inférieurs. Ces propositions concernent aussi le rôle potentiel des tests fonctionnels plaquettaires, la gestion des AAP pour l’anesthésie locorégionale, centrale et périphérique, et pour la chirurgie cardiaque coronaire.

International audience; BACKGROUND: Because of the high risk of thrombotic complications (TCs) during SARS-CoV-2 infection, several scientific societies have proposed to increase the dose of preventive anticoagulation, although arguments in favor of this strategy are inconsistent. RESEARCH QUESTION: What is the incidence of TC in critically ill patients with COVID-19 and what is the relationship between the dose of anticoagulant therapy and the incidence of TC? STUDY DESIGN AND METHODS: All consecutive patients referred to eight French ICUs for COVID-19 were included in this observational study. Clinical and laboratory data were collected from ICU admission to day 14, including anticoagulation status and thrombotic and hemorrhagic events. The effect of high-dose prophylactic anticoagulation (either at intermediate or equivalent to therapeutic dose), defined using a standardized protocol of classification, was assessed using a time-varying exposure model using inverse probability of treatment weight. RESULTS: Of 538 patients included, 104 patients experienced a total of 122 TCs with an incidence of 22.7% (95% CI, 19.2%-26.3%). Pulmonary embolism accounted for 52% of the recorded TCs. High-dose prophylactic anticoagulation was associated with a significant reduced risk of TC (hazard ratio, 0.81; 95% CI, 0.66-0.99) without increasing the risk of bleeding (HR, 1.11; 95% CI, 0.70-1.75). INTERPRETATION: High-dose prophylactic anticoagulation is associated with a reduction in thrombotic complications in critically ill patients with COVID-19 without an increased risk of hemorrhage. Randomized controlled trials comparing prophylaxis with higher doses of anticoagulants are needed to confirm these results.

Background Lower limb trauma requiring immobilization is a significant contributor to overall venous thromboembolism (VTE) burden. The clinical effectiveness of thromboprophylaxis for this indication and the optimal agent strategy are still a matter of debate. Our main objective was to assess the efficacy of pharmacological thromboprophylaxis to prevent VTE in patients with isolated temporary lower limb immobilization after trauma. We aimed to estimate and compare the clinical efficacy and the safety of the different thromboprophylactic treatments to determine the best strategy. Methods and findings We conducted a systematic review and a Bayesian network meta-analysis (NMA) including all available randomized trials comparing a pharmacological thromboprophylactic treatment to placebo or to no treatment in patients with leg immobilization after trauma. We searched Medline, Embase, and Web of Science until July 2021. Only RCT or observational studies with analysis of confounding factors including adult patients requiring temporary immobilization for an isolated lower limb injury treated conservatively or surgically and assessing pharmacological thromboprophylactic agents or placebo or no treatment were eligible for inclusion. The primary endpoint was the incidence of major VTE (proximal deep vein thrombosis, symptomatic VTE, and pulmonary embolism-related death). We extracted data according to Preferred Reporting Items for Systematic Reviews and Meta-analyses for NMA and appraised selected trials with the Cochrane review handbook. Fourteen studies were included (8,198 patients). Compared to the control group, rivaroxaban, fondaparinux, and low molecular weight heparins were associated with a significant risk reduction of major VTE with an odds ratio of 0.02 (95% credible interval (CrI) 0.00 to 0.19), 0.22 (95% CrI 0.06 to 0.65), and 0.32 (95% CrI 0.15 to 0.56), respectively. No increase of the major bleeding risk was observed with either treatment. Rivaroxaban has the highest likelihood of being ranked top in terms of efficacy and net clinical benefit. The main limitation is that the network had as many indirect comparisons as direct comparisons. Conclusions This NMA confirms the favorable benefit/risk ratio of thromboprophylaxis for patients with leg immobilization after trauma with the highest level of evidence for rivaroxaban. Trial registration PROSPERO CRD42021257669.

Pressure-induced tissue strain is one major pathway for Pressure Ulcer development and, especially, Deep Tissue Injury. Biomechanical investigation of the time-dependent stress-strain mechanical behaviour of skeletal muscle tissue is therefore essential. In the literature, a viscoelastic formulation is generally assumed for the experimental characterization of skeletal muscles, with the limitation that the underlying physical mechanisms that give rise to the time dependent stress-strain behaviour are not known. The objective of this study is to explore the capability of poroelasticity to reproduce the apparent viscoelastic behaviour of passive muscle tissue under confined compression.Experimental stress-relaxation response of 31 cylindrical porcine samples tested under fast and slow confined compression by Vaidya and collaborators were used. An axisymmetric Finite Element model was developed in ABAQUS and, for each sample a one-to-one inverse analysis was performed to calibrate the specimen-specific constitutive parameters, namely, the drained Young's modulus, the void ratio, hydraulic permeability, the Poisson's ratio, the solid grain's and fluid's bulk moduli.The peak stress and consolidation were recovered for most of the samples (N=25) by the poroelastic model (normalised root-mean-square error ≤0.03 for fast and slow confined compression conditions).The strength of the proposed model is its fewer number of variables (N=6 for the proposed poroelastic model versus N=18 for the viscohyperelastic model proposed by Vaidya and collaborators). The incorporation of poroelasticity to clinical models of Pessure Ulcer formation could lead to more precise and mechanistic explorations of soft tissue injury risk factors.

Heparin-induced thrombocytopenia (HIT) is a rare, iatrogenic disease characterised by its potential severity, mainly related to thrombosis, and by difficulties regarding its diagnosis and management of affected patients. In 2002, a conference of experts mobilised by the French Society of Anaesthesia and Intensive Care Medicine (Société française d’anesthésie et de réanimation [SFAR]) drafted recommendations for the management of HIT [...]

Introduction Postoperative ileus(POI) and anastomotic leakage(AL) are highly associated but the direction of this link is unknown. Indeed, it has traditionally been stated that AL leads to POI(secondary POI). The objective was to statistically determine the best model of link between POI and AL by comparing different Structural Equation Models(SEM). Methods This is a retrospective analysis of a prospective multicentric database from the Francophone Group for Enhanced Recovery after surgery(GRACE) including patients undergoing colorectal resection or Hartmann reversal between 2014 and 2017. The main outcome measure was the occurrence of postoperative ileus defined by the absence of Gastrointestinal (GI)-3 recovery in or after postoperative day 4 and the occurrence of AL. Results Among the 2227 patients included, 223 patients experienced POI (10 %) and 72 patients experienced anastomotic leakage (3.2 %). In all the models, POI was significantly increased in case of male gender, older age, opioids consumption, right colectomy, chronic obstructive bronchopneumopathy disease and performance of a stoma, and reduced by Enhanced Recovery Programs (ERP) compliance ≥ 70 % and intake of Non-Steroidal Anti-Inflammatory Drugs. Open surgery was not significantly associated with POI in all the models. In contrast, the male gender was the only factor increasing AL in the model drawn with ERP risk factors for AL. In all the models, POI was highly associated with AL and statistical analyses advocate for POI leading to AL. Conclusion The findings of the present large study suggest that the more statistically probable model is the one in which POI come first before AL.

International audience

The French Working Group on Perioperative Haemostasis (GIHP) and the French Study Group on Haemostasis and Thrombosis (GFHT) in collaboration with the French Society for Anaesthesia and Intensive Care Medicine (SFAR) drafted up-to-date proposals for the management of antiplatelet therapy in patients undergoing elective invasive procedures. The proposals were discussed and validated by a vote; all proposals but one could be assigned with a high strength. The management of antiplatelet therapy is based on their indication and the procedure. The risk of bleeding related to the procedure can be divided into high, moderate and low categories depending on the possibility of performing the procedure in patients receiving antiplatelet agents (none, monotherapy and dual antiplatelet therapy respectively). If discontinuation of antiplatelet therapy is indicated before the procedure, a last intake of aspirin, clopidogrel, ticagrelor and prasugrel 3, 5, 5 and 7 days before surgery respectively is proposed. The thrombotic risk associated with discontinuation should be assessed according to each specific indication of antiplatelet therapy and is higher for patients receiving dual therapy for coronary artery disease (with further refinements based on a few well-accepted items) than for those receiving monotherapy for cardiovascular prevention, for secondary stroke prevention or for lower extremity arterial disease. These proposals also address the issue of the potential role of platelet functional tests and consider management of antiplatelet therapy for regional anaesthesia, including central neuraxial anaesthesia and peripheral nerve blocks, and for coronary artery surgery., SCOPUS: ar.j, info:eu-repo/semantics/published

Context Epidemiological evidence that the risk of coronary heart disease is inversely associated with the level of high-density lipoprotein cholesterol (HDL-C) has motivated several phase III programmes with cholesteryl ester transfer protein (CETP) inhibitors. Objectives To assess alternative methods to predict clinical response of CETP inhibitors. Methods Meta-regression analysis on raising HDL-C drugs (statins, fibrates, niacin) in randomised controlled trials. Results 51 trials in secondary prevention with a total of 167 311 patients for a follow-up >1 year where HDL-C was measured at baseline and during treatment. The meta-regression analysis showed no significant association between change in HDL-C (treatment vs comparator) and log risk ratio (RR) of clinical endpoint (non-fatal myocardial infarction or cardiac death). CETP inhibitors data are consistent with this finding (RR: 1.03; P5–P95: 0.99–1.21). A prespecified sensitivity analysis by drug class suggested that the strength of relationship might differ between pharmacological groups. A significant association for both statins (p 2 =0.21) and niacin (p=0.02, log RR=1.07–0.185*HDL-C change, R 2 =0.61) but not fibrates (p=0.18, log RR=−0.367+0.077*HDL-C change, R 2 =0.40) was shown. However, the association was no longer detectable after adjustment for low-density lipoprotein cholesterol for statins or exclusion of open trials for niacin. Conclusions Meta-regression suggested that CETP inhibitors might not influence coronary risk. The relation between change in HDL-C level and clinical endpoint may be drug dependent, which limits the use of HDL-C as a surrogate marker of coronary events. Other markers of HDL function may be more relevant.

Enhanced recovery programs (ERP) improve post-operative outcomes in proportion to how fully they are implemented. Maintaining an optimal level of application of all the ER components is thus essential. Our aim was to assess the sustainability of ER surgical components 2 years after their first implementation.Patients undergoing elective colorectal resections were included in a prospective database. To retrospectively analyze compliance with ERP over a period of 24 months, the following components were considered: colonic preparation, surgical approach, nasogastric tube omission and absence of abdominal drainage.2565 patients with a mean age of 63.6 ± 14.4 years from 63 colorectal centers were included. There were 1853 (72.2%) colectomies and 558 (21.7%) rectal resections. The median duration of hospital stay was 5 days [Interquartiles 4-8]. Overall morbidity was 21.9%, surgical morbidity was 8.1%, including 2.8% anastomotic fistulae. Overall, the ERP component most often applied with was postoperative nasogastric tube omission (93.6%), followed by laparoscopic approach (81.7%), absence of drainage (74.9%), and colonic preparation omission (67.3%). Implementation of surgical components significantly decreased over time: less laparoscopy (from 86.8% to 76.6%, p 0.001), less drain omission (from 88.7% to 72%, p 0.001), less nasogastric tube omission (from 100% to 93.4%, p = 0.002) and less colonic preparation omission (from 73.6% to 65.6%, p = 0.01).This large-scale study found that implementation of surgical components in ERP decreased over time. Further efforts are needed to sustain compliance with ERP and surgical teams should focus on repeated audits.

La meta-analyse sur donnees resumees permet de combiner les estimations ponctuelles de plusieurs etudes afin de fournir une synthese precise des connaissances disponibles. L’influence d’un facteur explicatif peut etre etudiee a l’aide de techniques de meta-regression lineaire voire non-lineaire. Cependant, dans certains cas le resultat des etudes n’est pas donne sous la forme d’une estimation ponctuelle mais d’une fonction correspondant a un modele de regression. C’est notamment le cas des donnees issues d’etudes de pharmacocinetiques de population, dans lesquelles la clairance d’elimination du medicament peut etre representee a l’aide d’un modele de regression prenant en compte une covariable explicative. La Fig. 1 represente les donnees disponibles dans la litterature concernant la relation entre clairance d’elimination de l’apixaban et le debit de filtration glomerulaire (DFG). Dans ce cas precis, les techniques classiques de meta-analyse sont insuffisantes ne permettant pas de prendre en compte les estimations de nature fonctionnelle. Dans ce travail, nous decrivons la construction d’un estimateur permettant l’analyse conjointe de donnees ponctuelles et de donnees fonctionnelles. Cet estimateur repose sur une decomposition de la fonction de meta-regression dans une base de b-splines. L’estimation des coefficients de cette decomposition est realisee en utilisant un critere des moindres carres prenant en compte : – la precision d’estimations des parametres de chacun des modeles de la litterature ; – la plage des valeurs de la variable explicative exploree dans chacune des etudes. Les estimations ponctuelles sont considerees comme des fonctions constantes. L’estimateur des moindres carres propose possede une solution explicite. Nous verrons qu’il est possible d’imposer differents types de contrainte de forme (monotonie, concavite/convexite, monotonie et concavite/convexite). Dans ce cas, la solution n’est plus explicite et est obtenue en resolvant un probleme d’optimisation quadratique sous contrainte. L’ensemble des resultats sera illustre sur les donnees de la relation entre clairance de l’apixaban et le DFG. La figure 1 represente la fonction de meta-regression obtenue a partir des donnees de l’apixaban en imposant une contrainte de monotonie et de concavite ainsi que son intervalle de confiance estime par bootstrap.( Fig. 1 )

Enteroviruses (EV) are a common cause of aseptic meningitis in children. Virological diagnosis of EV meningitis is currently based on the detection of the viral genome in the cerebrospinal fluid (CSF). This study attempted to determine the correlation and the temporality of the polymerase chain reaction (PCR) assay in serum and CSF and to evaluate the possibility of diagnosing EV infection only on the serum PCR. The EV genome was sought by RT real-time PCR (Smart Cycler EV Primer and Probe Set(®), Cepheid) in CSF and serum, collected at the same time, for all children who underwent a lumbar puncture for suspected meningitis, between 1 June and 31 July 2010 at the Versailles Hospital. Forty-four patients were included in the study. EV infection was documented for 22 of them. In 10 patients, the EV genome was detected in CSF only; in 3 patients in serum only, and in 9 patients in both. Among patients with acute EV neurological infection, viremic children were significantly younger (1.6 months versus 5.8 years; P 3 months, clinical and biological compatibility with a viral infection, no previous antibiotic therapy, time from symptom onset to blood sampling

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 41 - N° 7 - p. 668-671

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 41 - N° 2 - p. 128-135

Dabigatran (Pradaxa) is a new oral, direct, selective and reversible inhibitor of the factor IIa of the coagulation cascade. The main pharmacokinetic characteristics of dabigatran are a bioavailability of approximately 7.5%, a maximum concentration obtained in 0.5 to 2 hours, a terminal half-life of elimination of 7 to 17 hours, a renal way of elimination, 80% as unchanged form and 20% as glucuronide conjugate. The main sources of variability are the renal function, the gastric motility, especially during the early post-operative period and a potential interaction with amiodarone. This compound can be orally administrated, once or twice daily, without any biological monitoring and without any need for dose adjustment. There is a contra-indication in case of severe renal or liver insufficiency. Two phases II with 2287 patients were carried out to for venous thromboembolic (VTE) prophylaxis after major orthopaedic surgery, showing that 150 mg and 220 mg once daily could be the optimal dose regimen to assess in phase III. One phase II with 502 patients vas carried out for the prevention of thromboembolic complications of atrial fibrillation (AF) showing that 110 mg or 150 mg twice daily could be the optimal dose regimen to evaluate in the following phases 3. From this study in AF patients, a dose regimen of 150 mg bid has been chosen to be evaluated for the treatment of VTE. No strong signal for a potential liver toxicity was shown during these studies.

Rivaroxaban (Xarelto) is a new oral, direct and selective inhibitor of the factor Xa of the coagulation cascade. The main pharmacokinetic characteristics of rivaroxaban are a bioavailability of approximately 80-100%, a maximum concentration obtained in 2 to 4 hours, a terminal half-life of elimination of 7 to 11 hours, a renal elimination for 1/3 for the active hepatic metabolism from the cytochrome P450 (3A4) for the other 2/3. The main sources of variability are the renal and the liver function and potential interactions with some strong inhibitors or inducers of the CYP450 3A4. Phase II clinical studies have shown that this compound can be orally administrated, once or twice daily, without any biological monitoring and without any need for dose adjustment. There is a contra-indication in case of severe liver insufficiency and not recommended in case of severe renal impairment. Pharmacodynamically, Rivaroxaban is a direct and selective factor Xa inhibitor without any effect on the factor IIa and without any interaction on platelets. Four phases II with 2787 patients were carried out to for venous thromboembolic (VTE) prophylaxis after major orthopaedic surgery, showing that 10 mg once daily could be the optimal dose regimen to assess in phase III. Two phases II with 1446 patients were carried out for the treatment of VTE showing that 15 mg twice daily for 3 weeks and then 20 mg once daily could be the optimal dose regimen to evaluate in the following phases 3. No strong signal for a potential liver toxicity was shown during these 6 phases II.

The objective of the study was to evaluate the influence of anticoagulation on intrapartum anesthesia and delivery modalities.This ancillary study is concerned with anticoagulated patients included in the study STRATHEGE, in the Saint-Etienne and Lyon University Hospital from 2007 to 2012, which are compared to a control population. The primary endpoint is to evaluate the type of anesthesia received by women in labor, according to the center at the time of delivery compared to no treatment. The secondary endpoints are comparing the input mode to work, mode of delivery, stop management arrangements of these treatments, the rate of thromboembolic and hemorrhagic complications.Two hundred and three cases were included and 812 controls, matched on age, body mass index and parity. 61.6% of the cases had an epidural during childbirth against 87% of controls (p0.05), spinal rates (22.5% versus 1.85%) and general anesthesia (5.4% versus 0.7%) were higher in the case group. The delivery rate vaginally was 90% in controls, against 65% of cases. The postpartum hemorrhage rate was similar in both groups (p0.05). A relay of the low molecular weight heparin was performed in 63% of the cases in Lyon, but the types of anesthesia received according to the centers were similar.Anticoagulant therapy at the time of delivery, does not limit access to effective analgesia, but with an increased rate of spinal anesthesia and general anesthesia at the expense of epidural anesthesia. The management of a parturient anticoagulant is complex and still exists today, great care disparities in the various maternity hospitals.

Objectives The aim of this study was to evaluate the proportion of transfer letters that contained information relative to infection or colonization by multidrug-resistant (MDR) bacteria and factors associated with the presence of that information. Patients and methods Patients for whom at least one of these selected MDR bacteria (methicillin-resistant Staphylococcus aureus , extended-spectrum β-lactamase-producing Enterobacteriaceae , or MDR Pseudomonas aeruginosa ) was isolated during their hospitalization and who were transferred to another health care facility between 2009 and 2012 were included. Information of the MDR bacterium and the mention of isolation precautions were evaluated in the electronic medical record. Results Information (mention of MDR bacterium or isolation precaution) was present in 57% [52; 65] of records. Full information (genus and species, concept of MDR bacterium and mention of isolation precaution) was found in 20% [16; 25]. The presence of a dedicated item in the standard medical discharge letter was associated with more frequent information. Less information was retrieved with P. aeruginosa cases than with the other 2 MDR bacteria. Conclusion The presence of the information has improved, but it is still insufficiently reported. Measures to improve information are needed. Indeed, information on MDR bacterial colonization or infection is the first step for isolation precautions. An item could be added to all standard medical discharge letters. An item could also be added to the indicators used to assess quality and safety in healthcare facilities.

Resume Objectifs. – Determiner si la survenue a un âge tres eleve, c'est-a-dire au-dela de 80 ans d'un AVC constitue un facteur pronostique significatif de mortalite, d'orientation dans une filiere de soins apres la phase aigue et de devenir fonctionnel a six mois. Materiel. – Etude prospective de 112 sujets recrutes consecutivement sur une periode de six mois dans un service d'urgence ou ils etaient admis pour un premier AVC avec hemiplegie et/ou aphasie. Quarante-sept des 112 patients avaient plus de 80 ans. Methode. – Apres un diagnostic initial et inclusion dans l'etude, chaque sujet beneficie d'une evaluation dans les 48 premieres heures, a 15 jours et a six mois avec recueil de donnees demographiques, cliniques, radiologiques et cotations du National institute of health stroke scale (NIHSS), mini mental status examination (MMSE), index de Barthel (IB), mesure d'independance fonctionnelle (MIF) et mesure d'adaptation fonctionnelle (MAF). Etude statistique descriptive et application de tests de comparaison avec recherche de variables unies puis multivariees significatives. Resultats. – Les sujets âges de 80 ans et plus presentent un taux de mortalite plus eleve, une moindre possibilite d'orientation en service de reeducation et de retour a domicile mais ne presentent pas un plus mauvais devenir fonctionnel a six mois. Discussion. – Ces resultats demontrent de maniere specifique qu'un âge tres eleve, au-dela de 80 ans, est souvent discriminant dans la prise en charge ou dans l'orientation des patients, sans autre critere objectif apparent. C'est aussi un facteur de placement en institution. Conclusion. – Des etudes complementaires sont necessaires pour evaluer le benefice fonctionnel d'une reeducation specifique pour ces patients tres âges en tenant compte du cout et des risques eleves de recidive ou de deces.

The thromboembolic risk related to surgery may be considered as low for varicose vein surgery and non major digestive surgery. It could be defined as moderate in case of large dissection, long duration of procedures and emergency cases. The risk may be considered as high for major abdominal surgery involving cancer surgery or not and bariatric surgery. The absence of prophylaxis can be proposed for low risk surgery (grade B). However, elastic compression stocking are effective for all cases of digestive surgery and suggested to be used (grade A). There are no data concerning the moderate risk situation. Therefore, experts recommend the use of elastic compression stockings or low doses of LMWH (grade D). High-risk surgery requires the use of high doses of LMWH recommended for reasons of efficacy, tolerance, and easiness to use (grade A). Associated elastic stockings is efficious (grade B). The duration of prophylaxis lasts generally 7-10 days. Extension to 1 month is recommended for major abdominal cancer surgery (grade A).

Resume But de lˈetude : La morbidite des retablissements de continuite apres intervention de Hartmann est importante. Le but de cette etude etait d’evaluer la faisabilite et les resultats d’une approche laparoscopique de ces retablissements de continuite digestive. Patients et methode : Trente-huit patients, dont l’âge moyen etait de 60 ± 13,5 ans ont ete inclus dans cette etude. L’indication principale des procedures de Hartmann etait les maladies diverticulaires (70 %). Le delai moyen entre l’intervention de Hartmann et le retablissement laparoscopique etait de 136 ± 24 jours. Un abord peristomial premier etait effectue chez 24 patients, autorisant l’introduction du premier trocart. Chez les 14 patients restants une open cœlioscopie ombilicale etait realisee. L’importance des phenomenes adherentiels etait evaluee comme faible chez 13 patients, moderee chez 15 patients et majeure chez dix patients. Toutes les anastomoses etaient mecaniques trans-suturaires. Resultats : Le taux de conversion etait de 15 %, pour adherences majeures (n = 5) ou un test d’etancheite anastomotique positif (n = 1). La morbidite etait de 23,5 % incluant huit complications chirurgicales. La mortalite etait de 2,6 % (une peritonite postoperatoire). La duree moyenne d’hospitalisation etait de10 ± 4,4 jours. Conclusion : Nos resultats suggerent que le retablissement de continuite laparoscopique apres intervention de Hartmann est faisable et sure. La presence d’une peritonite generalisee lors de la premiere intervention, ou un trop court delai entre les deux procedures sont des facteurs de conversion en laparotomie.

We used perceptual motor tasks involving the learning of mouse control by looking at a Macintosh computer screen. We studied 90 control subjects aged between sixteen and seventy-five years. There was a significant time difference between the scales of age but improvement was the same for all subjects. We also studied 24 patients with Parkinson's disease (PD). We observed an influence of age and also of educational levels. The PD patients had difficulties of learning in all tests but they did not show differences in time when compared to the control group in the first learning session (Student's t-test). They learned two or four and a half times less well than the control group. In the first test, they had some difficulty in initiating the procedure and learned eight times less well than the control group. Performances seemed to be heterogeneous: patients with only tremor (seven) and patients without treatment (five) performed better than others but learned less. Success in procedural tasks for the PD group seemed to depend on the capacity to initiate the response and not on the development of an accurate strategy. Many questions still remain unanswered, and we have to study different kinds of implicit memory tasks to differentiate performance in control and basal ganglia groups.

Robotic assisted laparoscopic surgery allows for a more precise dissection than classical laparoscopic surgery. However, it sometimes imposes specific exaggerated postures and extralong procedure duration. Combining these two factors may increase the risk for postural complications in at-risk patients. We report the case of an obese 30-year-old female patient who underwent a 12-hour duration robotic laparoscopic surgery for severe endometriosis, in Trendelenburg position. This was complicated by a two forearms rhabdomyolysis, with subsequent compartment syndrome with multiple neuropathy. Physicians must be aware of the cumulative risk for postural complications when extreme positions are associated to long duration procedures in predisposed patients.

Resume Introduction — Le traitement heparinique adjuvant de l’erysipele est d’usage courant. Materiel et methodes — Dans la litterature, deux etudes ont etudie systematiquement l’incidence des thromboses veineuses profondes (TVP) lors des erysipeles: Mahe (six TVP/40 erysipeles), et Perrot (quatre TVP/155 erysipeles). L’incidence relative calculee de toutes les etudes recherchant les TVP est de 4,9 %. Les autres etudes rapportent des complications a type de TVP cliniques. L’incidence relative calculee est de 0,7 % quand il n’est pas associe de traitement adjuvant par heparine. L’incidence relative calculee est de 0 %, intervalle de confiance a 95 % non significatif, quand un traitement adjuvant par heparine est associe. Les principales complications des traitements par heparine sont: la thrombopenie dans 5,7 et 0,9 % des traitements par heparine, standards et fractionnees; les hemorragies dans moins de 3 % des traitements a dose curative des TVP. Discussions — Le risque de TVP est risque faible. L’incidence des TVP occultes est superieure aux formes symptomatiques. Actuellement, il n’est pas demontre qu’il existe une equivalence entre les manifestations symptomatiques et asymptomatiques des TVP. Par ailleurs, les differentes conferences de consensus ne recommandent pas de traiter les malades alites avec risque thromboembolique faible. Conclusion — II n’y a pas d’indication de traitement anticoagulant efficace lors du traitement des erysipeles. II n’y a pas d’indication de traitement anticoagulant preventif de principe lors du traitement des erysipeles. Celui-ci depend des autres facteurs de risque de TVP du malade. II existe un possible interet du port de bande de contention elastique.

Enteroviruses (EV) are a common cause of aseptic meningitis in children. Virological diagnosis of EV meningitis is currently based on the detection of the viral genome in the cerebrospinal fluid (CSF). This study attempted to determine the correlation and the temporality of the polymerase chain reaction (PCR) assay in serum and CSF and to evaluate the possibility of diagnosing EV infection only on the serum PCR. The EV genome was sought by RT real-time PCR (Smart Cycler EV Primer and Probe Set(®), Cepheid) in CSF and serum, collected at the same time, for all children who underwent a lumbar puncture for suspected meningitis, between 1 June and 31 July 2010 at the Versailles Hospital. Forty-four patients were included in the study. EV infection was documented for 22 of them. In 10 patients, the EV genome was detected in CSF only; in 3 patients in serum only, and in 9 patients in both. Among patients with acute EV neurological infection, viremic children were significantly younger (1.6 months versus 5.8 years; P0.001). Viremia was detected when the serum was sampled within 30 h after the beginning of symptoms. These results confirm previous reports of early and transient viremia in young children. This preliminary study shows the limits and added value of EV PCR in serum. It suggests that in some children and under certain conditions (age3 months, clinical and biological compatibility with a viral infection, no previous antibiotic therapy, time from symptom onset to blood sampling30 h, PCR in serum analyzed within 3h), PCR in serum, when positive, is a possible alternative. Therefore, it may be possible to diagnose EV infection without performing a lumbar puncture in a limited number of young children (11.4% of our suspected cases). This study needs to be reinforced by a multicenter study with a broader panel of patients.

Resume Les auteurs etudient la memoire procedurale de 102 sujets sains âges de 16 a 85 ans avec un protocole d'apprentissage d'habiletes visuomotrices utilisant la souris et l'ecran de l'ordinateur et ce lors de trois seances. On realise une analyse de variance (Anova) sur donnees repetees dans le temps en prenant en compte les facteurs suivants: âge, sexe, niveau culturel, quotient intellectuel pratique (QIP) et situation de la seance pour les six tests consideres: tableau noir, taches, traits, labyrinthe, figures, ecriture. Seul l'âge a un effet significatif sur les performances: les sujets ont des temps d'execution qui augmentent avec l'âge mais un apprentissage comparable de 16 a 85 ans. Le niveau culturel et le QIP n'influencent pas les performances. Les hommes sont plus rapides dans trois des six tests. La conservation de l'apprentissage de tâches d'habiletes perceptivomotrices, par le sujet âge est rapportee a un traitement perceptif elementaire, probablement acquis tres tot.

Endometriosis concerns 10% of childbearing age women and frequently affects the digestive tract. We report here the case of a 31-year-old patient presenting a severe occlusive syndrome while being treated with GnRH agonist, within the framework of an in vitro fertilization. The surgical treatment will find a deep endometriosis affecting the sigmoid and colorectal junction and leading to a colorectal resection. These endometriosis lesion recurrences during ovarian stimulation or by GnRH flare up effect is rare and often debated. The surgical treatment of the lesions, before the medically assisted procreation, seems to prevent these complications.

Evaluation of mid-term functional results and the quality of life after laparoscopic colorectal resection.Twenty-three consecutive patients were included in a retrospective monocentric study. Postoperative functional outcomes and quality of life were analyzed.The median follow-up after colorectal resection was of 24±15.7 months (6-72). Major complications occurred in three cases (12,9%) including one anastomotic stenosis, one digestive and one bladder fistula. A significant improvement in pelvic pain symptoms was observed. De novo constipation and pain on defecation occurred in respectively 23% and 42% of the cases. Transient de novo dysuria occurred in 18% of the cases. The quality of life has been significantly improved.Laparoscopic colorectal resection is associated with unfavourable postoperative digestive and urological outcomes, such as bladder and rectal dysfunction. Radical treatment should be limited to selected patients.

Purpose Investigate if the combination of time-frequency domain analysis and ERG dipole rotation reveals hidden features of the normal ERG that could be instrumental in the interpretation of nearly extinguished ERG responses. Methods Analyses were conducted on photopic ERGs (Photopic Hills: PH) obtained from normal subjects (n=75) and patients (n=65) affected with various retinopathies. A Discrete Wavelet Transform (DWT) was done on each ERGs and key descriptors (Holder exponent and wavelet coefficient maxima) were calculated. Dipole rotation was obtained by combining 11 gaze positions (0, 8, 16, 24, 32 and 40 degrees nasal or temporal to center) with 4 electrode locations [corneal (CE), lower lid (LL), external (EC) and internal canthi (IC)]. Results The Holder exponent follows a parabola, while some of the local wavelet maxima seem to follow a PH-like like distribution (b-wave and OPs) or a logistic growth function (a-wave). In still recordable pathological ERGs, the wavelet maxima matched that found in normal ERGs evoked at low stimulus intensities while in nearly extinguished ERGs (

BSUMMARY BACKGROUND: Previous studies have shown an important risk of cardiovascular events in patients with clopidogrel biological non-response, and data have shown considerable, unexplored heterogeneity. OBJECTIVES: To evaluate the magnitude of cardiovascular risk associated with clopidogrel non-response and to explore heterogeneity. METHODS: This was a systematic review and meta-analysis of prospective studies of patients treated with clopidogrel for symptomatic atherothrombosis, evaluated by light transmission aggregometry with ADP and monitored prospectively for clinical ischemic events. RESULTS: Fifteen studies were included, totaling 3960 patients, of whom 25% were considered to be clopidogrel non-responders. The global relative risk (RR) for recurrent ischemic events in clopidogrel non-responders was 3.5 [95% confidence interval (CI) 2.4-5.2, P < 0.0001]. The results of the different studies were heterogeneous (Cochran P = 0.01 and I(2) = 52%). The most recent studies yielded lower RRs [global RR = 2.9 (95% CI 2.3-3.8) after 2007, and global RR = 6.6 (95% CI 3.7-11.9) before 2007, P = 0.01]. Heterogeneity was present in the group of studies in which more than 10% of patients took glycoprotein (GP)IIb-IIIa inhibitors [Cochran P = 0.003 and I(2) = 70%; RR = 3.8 (95% CI 2.9-5.1)] and was absent in the other studies [Cochran P = 0.88 and I(2) = 0; RR = 2.5 (95% CI 1.7-3.6)]. The RR was significantly higher in studies using higher ADP maximal aggregation cut-offs (> 65%) for clopidogrel non-response than in studies using lower cut-offs [RR = 5.8 (95% CI 3.2-10.3) and RR = 2.9 (95% CI 2.2-3.7), respectively, P = 0.03]. CONCLUSIONS: The risk of ischemic events associated with clopidogrel non-response is now more precisely defined. The risk is heterogeneous across studies, possibly because of an interaction with GPIIb-IIIa inhibitors and the use of different cut-offs to identify non-responders.

Robotic assisted laparoscopic surgery allows for a more precise dissection than classical laparoscopic surgery. However, it sometimes imposes specific exaggerated postures and extralong procedure duration. Combining these two factors may increase the risk for postural complications in at-risk patients. We report the case of an obese 30-year-old female patient who underwent a 12-hour duration robotic laparoscopic surgery for severe endometriosis, in Trendelenburg position. This was complicated by a two forearms rhabdomyolysis, with subsequent compartment syndrome with multiple neuropathy. Physicians must be aware of the cumulative risk for postural complications when extreme positions are associated to long duration procedures in predisposed patients.

Dabigatran (Pradaxa) is a new oral, direct, selective and reversible inhibitor of the factor IIa of the coagulation cascade. The main pharmacokinetic characteristics of dabigatran are a bioavailability of approximately 7.5%, a maximum concentration obtained in 0.5 to 2 hours, a terminal half-life of elimination of 7 to 17 hours, a renal way of elimination, 80% as unchanged form and 20% as glucuronide conjugate. The main sources of variability are the renal function, the gastric motility, especially during the early post-operative period and a potential interaction with amiodarone. This compound can be orally administrated, once or twice daily, without any biological monitoring and without any need for dose adjustment. There is a contra-indication in case of severe renal or liver insufficiency. Two phases II with 2287 patients were carried out to for venous thromboembolic (VTE) prophylaxis after major orthopaedic surgery, showing that 150 mg and 220 mg once daily could be the optimal dose regimen to assess in phase III. One phase II with 502 patients vas carried out for the prevention of thromboembolic complications of atrial fibrillation (AF) showing that 110 mg or 150 mg twice daily could be the optimal dose regimen to evaluate in the following phases 3. From this study in AF patients, a dose regimen of 150 mg bid has been chosen to be evaluated for the treatment of VTE. No strong signal for a potential liver toxicity was shown during these studies.

Rivaroxaban (Xarelto) is a new oral, direct and selective inhibitor of the factor Xa of the coagulation cascade. The main pharmacokinetic characteristics of rivaroxaban are a bioavailability of approximately 80-100%, a maximum concentration obtained in 2 to 4 hours, a terminal half-life of elimination of 7 to 11 hours, a renal elimination for 1/3 for the active hepatic metabolism from the cytochrome P450 (3A4) for the other 2/3. The main sources of variability are the renal and the liver function and potential interactions with some strong inhibitors or inducers of the CYP450 3A4. Phase II clinical studies have shown that this compound can be orally administrated, once or twice daily, without any biological monitoring and without any need for dose adjustment. There is a contra-indication in case of severe liver insufficiency and not recommended in case of severe renal impairment. Pharmacodynamically, Rivaroxaban is a direct and selective factor Xa inhibitor without any effect on the factor IIa and without any interaction on platelets. Four phases II with 2787 patients were carried out to for venous thromboembolic (VTE) prophylaxis after major orthopaedic surgery, showing that 10 mg once daily could be the optimal dose regimen to assess in phase III. Two phases II with 1446 patients were carried out for the treatment of VTE showing that 15 mg twice daily for 3 weeks and then 20 mg once daily could be the optimal dose regimen to evaluate in the following phases 3. No strong signal for a potential liver toxicity was shown during these 6 phases II.

Arterial thromboembolic disorders are the leading cause of death in most of the advanced nations. The study of epidemiologic relationship of these disorders to biological rhythms may lead to a better understanding and perhaps a better treatment. Chronoepidemiologic studies demonstrated a morning peak for arterial thromboembolic disorders (cerebral and myocardial infarctions) and sudden cardiac deaths. These variations might be explained partially by circadian variations in hemostasis. Indeed chronophysiologic studies have shown that hemostatic variables follow circadian rhythms. The level of platelet aggregation and that of blood coagulation have been found to be increased in the morning whereas fibrinolytic activity is lower at this time of the day. The facts suggest a chronotherapeutic approach in thromboembolic disorders.