Appropriateness of Antibiotic Prescription During Teleconsultation

Teleconsultation has become a new means of using care which has taken off significantly since the COVID crisis, The pooling of the technological environment within the TC makes it possible to set up practice reviews by reusing the data collected. Our aim was to evaluate the relevance of antibiotic therapy during teleconsultations carried out on the national teleconsultation platform "Qare" in 4 common infections. 143,428 TCs with structured prescriptions were analyzed, with an appropriate prescription in more than 82% of cases, higher than in the literature. The use of data makes it possible to quickly assess practices and inform doctors to improve their practices.

Intra-operative fluorescence angiography is reproducible and reduces the rate of anastomotic leak after colorectal resection for cancer: a prospective case-matched study

AIM

Intra-operative fluorescence angiography (IOFA) with indocyanine green provides information on tissue perfusion that may help prevent an anastomotic leak (AL). The aim of this study was to assess the impact of IOFA on outcomes after left-sided colonic or low anterior resection with anastomosis for colorectal cancer.

METHODS

All patients with left-sided colonic or rectal cancer, operated between June 2017 and December 2018, were prospectively included. IOFA has been routinely implemented since May 2018. Reproducibility of IOFA, after a 1:1 matching for relevant clinical risk factors of AL, was studied in patients with IOFA (IOFA+) and without IOFA (IOFA-). Outcomes were compared in terms of postoperative events such as clinically relevant AL as the primary end-point.

RESULTS

In the IOFA+ group, changing of the initially planned colon transection due to inadequate perfusion occurred in five out of 46 patients (10.9%). Agreement between intra-operative assessment and postoperative blind review of IOFA was deemed strong (Cohen's kappa index 0.893, 95% CI 0.788-0.998, P < 0.001). Among 111 patients, 42 matched patients were included in each group. There was significantly more clinically relevant AL in the IOFA- group compared to the IOFA+ group (16.7% vs 2.4%, P = 0.026) involving significantly more anastomotic dehiscence which required re-intervention (19% vs 2.4%, P = 0.014). Additionally, more descending colon ischaemia/necrosis was observed in the IOFA- group compared with the IOFA+ group (9.5% vs 0%, P = 0.040).

CONCLUSION

In this prospective case-matched study, IOFA decreased the occurrence of clinically relevant AL due to necrosis of the descending colon or anastomosis. Upon blind review, perfusion assessment using IOFA was reproducible.

The Regenerative Effect of Trans-spinal Magnetic Stimulation After Spinal Cord Injury: Mechanisms and Pathways Underlying the Effect

Spinal cord injury (SCI) leads to a loss of sensitive and motor functions. Currently, there is no therapeutic intervention offering a complete recovery. Here, we report that repetitive trans-spinal magnetic stimulation (rTSMS) can be a noninvasive SCI treatment that enhances tissue repair and functional recovery. Several techniques including immunohistochemical, behavioral, cells cultures, and proteomics have been performed. Moreover, different lesion paradigms, such as acute and chronic phase following SCI in wild-type and transgenic animals at different ages (juvenile, adult, and aged), have been used. We demonstrate that rTSMS modulates the lesion scar by decreasing fibrosis and inflammation and increases proliferation of spinal cord stem cells. Our results demonstrate also that rTSMS decreases demyelination, which contributes to axonal regrowth, neuronal survival, and locomotor recovery after SCI. This research provides evidence that rTSMS induces therapeutic effects in a preclinical rodent model and suggests possible translation to clinical application in humans.

Feasibility of encouraging participation in colorectal cancer screening campaigns by motivating people through the social network, Facebook

AIM

To describe the results of a feasibility phase and the expected results of a new approach to increase the participation rate in a Colorectal Cancer Organized Screening Program (CRCSP) through Facebook awareness messages.

METHOD

This approach targets people aged 50-74 years, who reside in an urban deprived area and regularly connect to Facebook. The feasibility phase ran over 2 months (December 2018 and January 2019) in six municipalities (Seine-Saint-Denis, France). The full provisional campaign will run over a year. The approach consists of sending electronic awareness messages on the importance of screening for colorectal cancer using a specific Facebook module. Subjects who consent to screening complete a test-kit application form. The eligibility of each subject to participate in screening is determined by a doctor before the kit is sent out.

RESULTS

A total of 39 900 people were reached by the feasibility phase campaign, and 9200 were able to watch at least one Facebook message/video. Of those, 4450 people logged to learn more about the CRCSP, 298 applied for a test kit, 160 test kit applicants were eligible to participate and the test completion rate was 41.9%. According to these feasibility results, 366 120 targeted people would connect regularly in the tested area, 141 541 of whom would be interested in a specific promotional message posted on Facebook. Requests could be made for 9770 kits, with 5246 people being eligible to participate in screening. The expected test-completion rate is estimated at 42%-89%. This would represent 5%-11% of the tests carried out in the area during the same period by 'classical' CRCSP.

CONCLUSION

Implementation of the Facebook strategy would significantly improve the rate of participation in the CRCSP by mobilizing people with no previous participation, including younger subjects.

Pragmatic Considerations on Clinical Decision Support from the 2019 Literature

Objectives : To summarize significant research contributions published in 2019 in the field of computerized clinical decision support and select the best papers for the Decision Support section of the International Medical Informatics Association (IMIA) Yearbook.

Methods : Two bibliographic databases were searched for papers referring to clinical decision support systems (CDSSs) and computerized provider order entry (CPOE) systems. From search results, section editors established a list of candidate best papers, which were then peer-reviewed by external reviewers. The IMIA Yearbook editorial committee finally selected the best papers on the basis of all reviews including the section editors’ evaluation.

Results : A total of 1,378 articles were retrieved. Fifteen best paper candidates were selected, the reviews of which resulted in the selection of three best papers. One paper reports on a guideline modeling approach based on clinical decision trees, both clinically interpretable and suitable for implementation in CDSSs. In another paper, authors promote the use of extended Timed Transition Diagrams in CDSSs to formalize consistently recurrent medical processes for chronic diseases management. The third paper proposes a conceptual framework and a grid for assessing the performance of predictive tools based on the critical appraisal of published evidence.

Conclusions : As showed by the number and the variety of works related to decision support, research in the field is very active. This year’s selection highlighted pragmatic works that promote transparency and trust required by decision support tools.

1133 The Recovery of Sleep Oscillations in Acute to Chronic Traumatic Brain Injury

Introduction

Slow waves and spindles are essential oscillations occurring during NREM sleep that may be disrupted by moderate to severe traumatic brain injury (TBI). We investigated these oscillations in the acute and chronic trauma stage.

Methods

Four groups were tested with whole-night polysomnography: hospitalized patients with acute TBI (n=10, 29.7±13.8y) or severe orthopedic injuries (n=15, 39.9±17.1y), chronic TBI including 9 returning from the acute TBI group (n=43, 31.9±13.5y), and healthy controls (n=36, 30.5±12.7y). Characteristics for slow waves (density, amplitude, slope, frequency, duration) and spindles (density, amplitude, frequency, duration) were quantified over N2 and N3 sleep for the first three sleep cycles, and groups were compared using one-way ANOVAs.

Results

One-way ANOVAs showed group effects only for slow wave density (F=4.11 to 6.04, p=0.009 to 0.0008)) and spindle density (F=3.3 to 8.8, p=0.02 to 0.00003). These effects were present for the 2nd and 3rd sleep cycles, but not the 1st. More specifically, slow wave density in acute TBI was higher than in controls, and returned to normal levels in the chronic stage. Conversely, spindle density in acute TBI was lower than in controls and returned to normal levels in the chronic stage. No group difference was observed for the orthopedic group.

Conclusion

Our results suggest that immediately after a severely disruptive event such as a TBI, the brain needs additional deeper sleep to recover, resulting in more slow waves but also in less spindles. These changes are only present in the 2nd and 3rd sleep cycles, reflecting an absence of the expected dissipation of slow waves, which may suggest increased homeostatic sleep pressure due to the brain injury. Limits to interpretation include the hospital environment and medication, but the absence of changes in the orthopedic group under similar conditions emphasizes the effect of the brain injury itself.

Support

Canadian Institutes of Health Research (CIHR) and Fonds de Recherche Québec-Santé (FRQS)

Structured Representation of Drug Indications: Lexical and Semantic Analysis and Object-Oriented Modeling

No standardized representation of drug indications is currently available that could be used in drug knowledge bases. We describe an object-oriented representation of indications that should make it possible to develop new tools for selecting drugs and checking prescriptions in computerized drug prescription systems. The model was developed using the results of a lexical and semantic analysis of drug indications, collected into a single file and processed using natural language processing software. It distinguishes both the diseases for which the drug may be given and the efficiency of the drug for a given indication. Two aspects of the model were evaluated: the differences if two independent evaluators filled the attributes independently and the loss of information induced by the use of the model. A system based on this model, making it possible for the physician to select all the drugs satisfying various criteria, is also presented.

Effect of liquid properties on swallowing and ventilation coordination in rats

BACKGROUND

One aspect of rehabilitation in swallowing disorders is to change liquid properties. The objective of our study was to test how liquid properties could improve oropharyngeal dysphagia and swallowing and ventilation coordination in an animal model.

METHODS

Forty-two healthy male rats were distributed in six groups, including a control group. Rats were deprived of water for 24 h and then each group was administered liquid with different properties: tap water, sugar water, sparkling water, salt water, cold water, and acidic water. Rats were studied without and with oropharyngeal dysphagia achieved by unilateral section of the hypoglossal nerve. Swallowing and ventilation were analyzed by barometric plethysmograph.

KEY RESULTS

In healthy rats, swallowing occurred during expiratory time for all liquid properties. Most deglutitions were during expiratory time for all liquid properties (88±12%) and were not modified. There was an increase in VT/TI during swallowing with sparkling water and cold water (P<.05). In the operated groups, rats had significantly fewer swallows with tap water (P<.05) and significantly more swallows with sparkling water (P<.001), sugar water (P<.001) and cold water (P<.001) during expiratory time. The mean inspiratory volume (VT/TI) increased with sparkling water (P<.05).

CONCLUSION AND INFERENCES

Sparkling water seemed to improve swallowing and ventilation coordination in an animal model, to be confirmed in a study including patients with oropharyngeal dysphagia.

An Algorithm Using Twelve Properties of Antibiotics to Find the Recommended Antibiotics, as in CPGs

BACKGROUND

Clinical Decision Support Systems (CDSS) incorporating justifications, updating and adjustable recommendations can considerably improve the quality of healthcare. We propose a new approach to the design of CDSS for empiric antibiotic prescription, based on implementation of the deeper medical reasoning used by experts in the development of clinical practice guidelines (CPGs), to deduce the recommended antibiotics.

METHODS

We investigated two methods ("exclusion" versus "scoring") for reproducing this reasoning based on antibiotic properties.

RESULTS

The "exclusion" method reproduced expert reasoning the more accurately, retrieving the full list of recommended antibiotics for almost all clinical situations.

DISCUSSION

This approach has several advantages: (i) it provides convincing explanations for physicians; (ii) updating could easily be incorporated into the CDSS; (iii) it can provide recommendations for clinical situations missing from CPGs.

Orthopedics coding and funding

The French tarification à l'activité (T2A) prospective payment system is a financial system in which a health-care institution's resources are based on performed activity. Activity is described via the PMSI medical information system (programme de médicalisation du système d'information). The PMSI classifies hospital cases by clinical and economic categories known as diagnosis-related groups (DRG), each with an associated price tag. Coding a hospital case involves giving as realistic a description as possible so as to categorize it in the right DRG and thus ensure appropriate payment. For this, it is essential to understand what determines the pricing of inpatient stay: namely, the code for the surgical procedure, the patient's principal diagnosis (reason for admission), codes for comorbidities (everything that adds to management burden), and the management of the length of inpatient stay. The PMSI is used to analyze the institution's activity and dynamism: change on previous year, relation to target, and comparison with competing institutions based on indicators such as the mean length of stay performance indicator (MLS PI). The T2A system improves overall care efficiency. Quality of care, however, is not presently taken account of in the payment made to the institution, as there are no indicators for this; work needs to be done on this topic.

A Preference-based framework for medical decision making

Medical decision making, such as choosing which drugs to prescribe, requires to consider mandatory constraints, e.g. absolute contraindications, but also preferences that may not be satisfiable, e.g. guideline recommendations or patient preferences. The major problem is that these preferences are complex, numerous and come from various sources. The considered criteria are often conflicting and the number of decisions is too large to be explicitly handled. In this paper, we propose a framework for encoding medical preferences using a new connective, called ordered disjunction symbolized by ~×. Intuitively, the preference "Diuretic~×Betablocker means: "Prescribe a Diuretic if possible, but if this is not possible, then prescribe a Betablocker". We give an inference method for reasoning about the preferences and we show how this framework can be applied to a part of a guideline for hypertension.

Modification in swallowing and ventilation co-ordination during hypercapnia, hypoxia, and tachypnea in unrestrained animals

BACKGROUND

It has been demonstrated that aspirations could occur during respiratory failure, explained by a lack of co-ordination between swallowing and ventilation. To test this hypothesis, we examined the co-ordination of ventilation and swallowing in a completely unrestrained rat model during different level of hypercapnia, during hypoxia, and during tachypnea.

METHODS

A total of 50 male Wistar rats (250-350 g) were studied in a barometric plethysmograph to analyze swallowing and ventilation during swallowing, at different gas concentration [room air (G1), 10% of O2 and 0% of CO2 (G2), 21% of O2 and 5% of CO2 (G3), 21% of O2 and 10% of CO2 (G4), tachypnea (G5)].

KEY RESULTS

During hypoxia, there was no difference between G2 and G1 regarding the swallowing parameters and ventilatory parameters. During hypercapnia, there was an increase in swallowing during inspiration in G4 (16 ± 20%P < 0.01) compared with G1. The analysis of ventilatory parameters during swallowing showed an increase in tidal volume (VT) and mean inspiratory time (VT/TI) (P < 0.001) with no change in respiratory cycle duration (TTOT), inspiratory time (TI), and expiratory time (TE) when compared with G1. During tachypnea (G5), the VT decreased (P < 0.05) without any change in VT/TI.

CONCLUSIONS & INFERENCES

Our results on animal demonstrated that hypercapnia increased swallowing during inspiration, which was not the case for tachypnea or hypoxia, and could explain some aspirations during respiratory failure.

Destabilizing and stabilizing forces to assess equilibrium during everyday activities

Postural stability is essential to functional activities. This paper presents a new model of dynamic stability which takes into account both the equilibrium associated with the body position over the base of support (destabilizing force) and the effort the subject needs to produce to keep his/her centre of mass inside the base of support (stabilizing force). The ratio between these two forces (destabilizing over stabilizing) is calculated to provide an overall index of stability for an individual. Preliminary results from data collected during walking at preferred and maximal safe speed in four older adults (aged from 64 to 84yr) showed that both forces are lower for subjects with reduced maximal gait speed. In addition, the stabilizing force increases by 2-3 times from preferred to maximal speed, while the destabilizing force barely changes with gait speed. Overall, the model through the index of stability attributes lower dynamic stability to subjects with lower maximal gait speed. These preliminary results call for larger-scale studies to pursue the development and validation of the model and its application to different functional tasks.

Vibration-induced post-effects: a means to improve postural asymmetry in lower leg amputees?

Muscle vibration has been shown to induce long-lasting and oriented alteration of standing posture in healthy individuals. The postural alterations can last several minutes following the end of vibration and are called post-effects. The goal of this study was to determine whether persons with lower leg amputation that show persistent postural asymmetry after usual rehabilitation experience these postural post-effects and if this could improve their weight bearing on the prosthesis. Centre of pressure (CP) position during stance was recorded prior to and up to 13 min after a 30s unilateral vibration applied during sitting to lateral neck (trapezius) or hip (gluteus medius) muscles in 14 individuals with unilateral lower leg amputation and 18 controls. The amputees' postural asymmetry was confirmed prior to the vibration intervention. A CP displacement, without an increase in CP velocity, was observed in both groups of participants over the 13 min post-vibration. For both the neck or hip vibration sites, the CP shifts were directed in the medio-lateral plane and were oriented either towards the vibrated side or the opposite side across subjects. This led to a decrease of postural asymmetry in half of the group of amputees. Within subject, the orientation of the post-effect was constant and changed to the opposite direction with vibration of the opposite body side. It is suggested that the post-effects are produced by a change of the postural reference consequent to the sustained proprioceptive message induced during the muscle vibration period. The orientation of the post-effects is discussed in relation to the notion of reference frame preference. All in all, because post-effect orientation is constant within subject and adaptive, future studies should investigate if individuals with lower leg amputation could benefit from postural post-effects induced by muscle vibration to improve function.

Cerebral correlates of the "Kohnstamm phenomenon": an fMRI study

This paper addresses the issue of the central correlates of the "Kohnstamm phenomenon", i.e. the long-lasting involuntary muscle contraction which develops after a prolonged isometric voluntary contraction. Although this phenomenon was described as early as 1915, the mechanisms underlying these post-effects are not yet understood. It was therefore proposed to investigate whether specific brain areas may be involved in the motor post-effects induced by either wrist muscle contraction or vibration using the fMRI method. For this purpose, experiments were carried out on the right wrist of 11 healthy subjects. Muscle activity (EMG) and regional cerebral blood flow were recorded during isometric voluntary muscle contraction and muscle vibration, as well as during the subsequent involuntary contractions (the post-effects) which occurred under both conditions. Brain activations were found to occur during the post-contraction and post-vibration periods, which were very similar under both conditions. Brain activation involved motor-related areas usually responsible for voluntary motor command (primary sensory and motor cortices, premotor cortex, anterior and posterior cingulate gyrus) and sensorimotor integration structures such as the posterior parietal cortex. Comparisons between the patterns of brain activation associated with the involuntary post-effects and those accompanying voluntary contraction showed that cerebellar vermis was activated during the post-effect periods whereas the supplementary motor area was activated only during the induction periods. Although post-effects originate from asymmetric proprioceptive inputs, they might also involve a central network where the motor and somatosensory areas and the cerebellum play a key role. In functional terms, they might result from the adaptive recalibration of the postural reference frame altered by the sustained proprioceptive inputs elicited by muscle contraction and vibration.

Efficacy of nitazoxanide and paromomycin in biliary tract cryptosporidiosis in an immunosuppressed gerbil model

OBJECTIVES

To evaluate the efficacy of nitazoxanide and paromomycin in biliary tract cryptosporidiosis in an immunosuppressed Mongolian gerbil (Meriones unguiculatus) model.

METHODS

Gerbils (1-month-old) were dexamethasone-immunosuppressed for 10 days and challenged orally with 10(5) Cryptosporidium parvum oocysts. From day 0 to day 12 post-infection, one group (n=14) was treated with 200 mg/kg/day nitazoxanide and another (n=15) with 100 mg/kg/day paromomycin. Infection and efficacy of nitazoxanide and paromomycin were assessed by measuring oocyst shedding in faeces, biliary tract and ileum histological examination.

RESULTS

In nitazoxanide-treated and paromomycin-treated groups as compared with untreated animals (P<0.05), oocyst shedding was partially suppressed in a similar manner (P>0.05). Parasites were present in histological sections of the ileal mucosa of 16/16 infected untreated animals versus 3/14 and 6/15 in the nitazoxanide-treated and the paromomycin-treated groups, respectively (P<0.05). In addition, gall bladder infection was less frequent in nitazoxanide-treated (2/14, P<0.01) and paromomycin-treated (5/15, P=0.07) animals than in untreated controls (9/16). No histological alteration of biliary mucosa was observed in both treated and untreated infected gerbils.

CONCLUSIONS

Present data support the efficacy of nitazoxanide and, to a lesser extent, paromomycin on biliary C. parvum infection in gerbils, and prompt further investigation of the potential clinical benefits of nitazoxanide in treating human biliary cryptosporidiosis.

Long-lasting body leanings following neck muscle isometric contractions

Our objective was to investigate the neural mechanisms and the functional relevance of motor effects that develop involuntarily following the release of a sustained isometric muscle contraction. The few data available in the literature deal only with post-contractions occurring in a body segment. Although these data emphasise the role of proprioceptive input, the question as to whether this phenomenon is of central or peripheral origin remains unclear. Given the leading role of neck muscle proprioceptive input in body orientation and posture regulation, we designed two experiments to test for postural posteffects after voluntary and involuntary neck muscle contraction. The spatiotemporal characteristics of the posteffects were analysed by means of stabilometric recordings following 30-s isometric contraction of splenius, trapezius and levator muscle groups, and 30-s electrically-induced contraction of the levator muscle group. Results show that a postural response occurred after voluntary contraction of each muscle group tested, which was oriented in the plane of action of the muscle, and lasted 14 min at least. In contrast, no clearly oriented body leanings were found after electrical stimulation of the levator muscle, except for a slight increase in natural postural instability. Data are interpreted as a change in the postural reference resulting from an increase in proprioceptive inflow accompanying mainly the voluntary muscle contraction.

[Factors associated with the choice of breast or bottle-feeding for hospitalized newborns]

This study was carried out in Rennes's maternity hospitals (France), to determine the breastfeeding rate for newborns hospitalized after birth, as well as the factors associated with the choice to breastfeed or not in these conditions.

METHODS

Three hundred and twenty mothers delivered in Rennes Teaching Hospital, whose neonates were transferred in neonatal care unit, were questioned about their choice for neonate feeding.

RESULTS

Three hundred and eight of the 320 mothers concerned by the study answered our interview. Fifty one percent of them chose to breast feed, which is near the breastfeeding rate of the general population of Rennes' maternity hospitals (52%). A high sociocultural level, a mother previously breastfed herself, and a previous breast feeding (RR = 5.2; P < 10(-8)) were associated with the choice of breastfeeding. Factors concerning the information of the mothers were also associated with the choice of breastfeeding information during the preparation to birth sessions (RR = 1.7; P < 10(-5)), individual information on the breastfeeding of an ill newborn (RR = 1.5; P < 0.01), and the simple advice to breastfeed given by a health care professional (RR = 2; P < 10(-8)). Of the four qualities named, the more breast-milk qualities a mother knew, the higher breastfeeding rate was (10% for none, 27% for one, 54% for two, and 76% for three or four). Concerning the postnatal factors, gestational age below 31 weeks multiplied breast feeding by 1.5 (P < 0.05), and an early contact mother-child (first day) by 1.3 (P < 0.05).

CONCLUSION

This study pointed out the populations at risk of no breastfeeding. Informations on the properties of breastfeeding given to mothers by health care professionals may influence them in their choice of breast feeding or not their ill newborn.

Structured representation of drug indications: lexical and semantic analysis and object-oriented modeling

No standardized representation of drug indications is currently available that could be used in drug knowledge bases. We describe an object-oriented representation of indications that should make it possible to develop new tools for selecting drugs and checking prescriptions in computerized drug prescription systems. The model was developed using the results of a lexical and semantic analysis of drug indications, collected into a single file and processed using natural language processing software. It distinguishes both the diseases for which the drug may be given and the efficiency of the drug for a given indication. Two aspects of the model were evaluated: the differences if two independent evaluators filled the attributes independently and the loss of information induced by the use of the model. A system based on this model, making it possible for the physician to select all the drugs satisfying various criteria, is also presented.