"The least significant change on bone mineral density scan increased in patients with higher degrees of obesity"

BACKGROUND

The least significant change (LSC) threshold of 0.03 g/cm² is used to interpret bone mineral density (BMD) scans in the general population. Our working hypothesis was that the current LSC threshold would not be applicable in obese populations.

AIMS

The aim of this study was to calculate the LSC in an obese population.

METHODS

We performed an interventional study among 120 obesity patients, in whom two measurements of BMD were performed at 3 sites. Pairs of measures were used to calculate the LSC, using the Bland and Altman method.

RESULTS

We calculated that the LSC was 0.046 g/cm² at the lumbar spine, 0.069 g/cm² at the femoral neck, and 0.06 g/cm² at the total hip. We also calculated the LSC for each class of obesity and observed an increase in LSC with increasing body mass index (BMI). We calculated a LSC of 0.05 g/cm² in patients with class 2 or class 3 obesity, whereas the LSC in patients with class 1 obesity is similar to the threshold used in the general population.

DISCUSSION

In obese population, like BMD, LSC is higher than the threshold value of the general population, and increases with increasing BMI.

CONCLUSION

LSC of 0.05 g/cm² could be used in clinical practice in patients with class 2 or 3 obesity. These findings should help to improve the interpretation of BMD scans in these patients and optimize their management.

TRIAL REGISTRATION NUMBER

Comité de Protection des Personnes Ile-de France VII, France.

Predictors of Nursing Home Entry within 36 Months after Hospitalization via the Emergency Department among Persons Aged 75 Years or Older

OBJECTIVE

We aimed to identify risk factors for nursing home (NH) entry 36 months after hospitalization via the emergency department (ED) in a population of patients aged 75 years or older.

METHODS

This was a prospective multicentre cohort. Patients were recruited from the emergency departments (EDs) of nine hospitals. Subjects had been hospitalised in a medical ward in the same hospital as the ED to which they were initially admitted. Subjects who experienced NH entry prior to ED admission were excluded. NH entry has been defined as the incident admission either into an NH or other long-term care facility within the follow-up period. Variables from a comprehensive geriatric assessment of patients were entered into a Cox model with competing risks to predict NH entry during 3 years of follow-up.

RESULTS

Among 1306 patients included in the SAFES cohort, 218 (16.7%) who were already in an NH were excluded. The remaining 1088 patients included in the analysis were aged 84 ± 6 years on average. During 3 years of follow-up, 340 (31.3%) entered an NH. The independent risk factors for NH entry were that they: living alone (Hazard ratio (HR) 2.00, had a 95% confidence interval (CI) 1.59-2.54, p < 0.0001), could not independently perform activities of daily living (HR 1.81, 95% CI 1.24-2.64, p = 0.002), and had balance disorders (HR 1.37, 95% CI 1.09-1.73, p = 0.007), dementia syndrome (HR 1.80, 95% CI 1.42-2.29, p < 0.0001) and a risk of pressure ulcers (HR 1.42, 95% CI 1.10-1.82, p = 0.006).

CONCLUSION

The majority of the risk factors for NH entry within 3 years after emergency hospitalization are amenable to intervention strategies. It is therefore reasonable to imagine that targeting these features of frailty could delay or prevent NH entry and improve the quality of life of these individuals before and after NH entry.

Risk Factors of Progression in Low-tumor Burden Follicular Lymphoma Initially Managed by Watch and Wait in the Era of PET and Rituximab

Patients (pts) with asymptomatic low-burden follicular lymphoma (FL) are usually observed at diagnosis. Time to lymphoma treatment (TLT) initiation can however be very heterogeneous and risk factors of progression are poorly studied. Our study evaluated 201 pts with grade 1-3a low-tumor burden FL diagnosed in four French centers between 2010 and 2020 and managed by a watch and wait strategy in real-life settings. After a median follow-up of 4.8 years, the median TLT was 4.2 years (95% confidence interval, 3.1-5.5). On multivariate analysis, elevated lactate dehydrogenase (hazard ratio [HR] = 2.2; P = 0.02), more than 4 nodal areas involved (HR = 1.7; P = 0.02) and more than 1 extranodal involvement (HR = 2.7; P = 0.01) were identified as independent predictors of TLT. The median TLT was 5.8 years for pts with no risk factor, 2.4 years for 1 risk factor, and 1.3 years for >1 risk factors (P < 0.01). In a subanalysis of 75 pts staged with positron emission tomography-computed tomography (PET-CT), total metabolic tumor volume (TMTV) ≥14 cm³ and standardized Dmax (reflecting tumor dissemination) >0.32 m^-1 were also associated with shorter TLT (HR = 3.4; P = 0.004 and HR = 2.4; P = 0.007, respectively). In multivariate models combining PET-CT parameters and clinical variables, TMTV remained independent predictor of shorter TLT. These simple parameters could help to identify FL patients initially observed at higher risk of early progression. The role of PET-CT (extranodal sites and PET metrics) in low-burden FL appears promising and warrants further assessment in large cohorts.

Development and validation of a ready-to-use score to prioritise medication reconciliation at patient admission in an orthopaedic and trauma department

OBJECTIVE

Medication reconciliation (MR) is recognised as an important tool in preventing medication errors such as unintentional discrepancies (UDs). The aim of this study was to identify independent predictive factors of UDs during MR at patient admission to an orthopaedic and trauma department. The secondary objective was to build and validate a ready-to-use score to prioritise patients.

METHOD

A retrospective study was performed on 3.5 years of pharmacist-led MR in the orthopaedic and trauma department of a large university teaching hospital. Independent predictors of UD were identified by multivariable logistic regression. A priority score to identify patients at risk of at least one UD was constructed from the odds ratios of the risk factors, and validated in a separate cohort. Performance was assessed with sensitivity, specificity, C-statistic and Hosmer-Lemeshow goodness-of-fit.

RESULTS

In total, 888 patients were included and 387 UDs were identified, mainly drug omissions (65.1%). Five independent predictors of UD were identified: age >75 years (OR 2.05, 95% CI 1.41 to 3.00; p<0.001), admission during school holidays (OR 1.69, 95% CI 1.17 to 2.44; p=0.005), female gender (OR 2.20, 95% CI 1.53 to 3.16; p<0.001), emergency hospitalisation (OR 2.05, 95% CI 1.45 to 2.92; p<0.001), and ≥5 medications on the best possible medication history (BPMH) (OR 3.29, 95% CI 2.20 to 4.94; p<0.001). Based on these predictors, a priority score ranging from 0 to 10 was built and internally and externally validated (C statistic 0.72, 95% CI 0.67 to 0.76).

CONCLUSIONS

This study confirms the high prevalence of UD in patients admitted to orthopaedic and trauma surgery departments. Five independent predictive factors of UD during MR were identified (female gender, emergency hospitalisation, hospitalisation during school holidays, age ≥75 years, and ≥5 medicines on the BPMH). The developed risk score will help to prioritise MR among patients at risk of medication error and is ready-to-use in other orthopaedic and trauma departments.

Fatigue and quality-of-life in the year following SARS-Cov2 infection

Background

The SARS-COV2 pandemic has been ongoing worldwide since at least 2 years. In severe cases, this infection triggers acute respiratory distress syndrome and quasi-systemic damage with a wide range of symptoms. Long-term physical and psychological consequences of this infection are therefore naturally present among these patients. The aim of this study was to describe the state of health of these patients at 6 (M6) and 12 months (M12) after infection onset, and compare quality-of-life (QOL) and fatigue at these time-points.

Methods

A prospective cohort study was set up at Reims University Hospital. Patients were clinically assessed at M6 and M12. Three scores were calculated to describe patient’s status: the modified Medical Research Council score (mMRC) used to determine dyspnoea state, the Fatigue Severity Scale (FSS) and the Short Form 12 (SF12) that was carried out to determine the QOL both mentally and physically (MCS12 and PCS12). Descriptive analysis and comparison of scores between M6 and M12 were made.

Results

120 patients completed both follow-up consultations. Overall, about 40% of the patients presented dyspnoea symptoms. The median mMRC score was 1 Interquartile ranges (IQR) = [0–2] at the two assessment. Concerning FSS scores, 35% and 44% of patients experienced fatigue at both follow-ups. The two scores of SF12 were lower than the general population standard scores. The mean PCS12 score was 42.85 (95% confidence interval (95% CI [41.05–44.65])) and mean MCS12 score of 46.70 (95% CI [45.34–48.06]) at 6 months. At 12 months, the mean PCS12 score was 42.18 (95% confidence interval (95% CI [40.46–43.89])) and mean MCS12 score of 47.13 (95% CI [45.98–48.28]). No difference was found between SF12 scores at 6 and 12 months.

Conclusions

This study pinpoints the persistence of fatigue and a low mental and physical QOL compared to population norms even after 1 year following infection. It also supports the claims of mental or psychological alterations due to infection by this new virus, hence a lower overall QOL in patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07517-w.

AB0992 Prognostic factors related to clinical response in 197 patients with knee osteoarthritis treated by platelet rich plasma (PRP)

Background

The European League Against Rheumatism (EULAR) [1] and the Osteoarthritis Research Society International (OARSI) [2] recommend a combination of non-pharmacological and pharmacological treatment in the management of knee osteoarthritis. New therapies have emerged such as Platelet Rich Plasma (PRP) injections. Many studies have shown the effectiveness of this treatment, and even its superiority over Hyaluronic Acid.

Objectives

The aim of this study was to determine the prognostic factors related to clinical response to PRP injections in knee osteoarthritis, in order to better select candidates for this therapy.

Methods

This was a single-center, prospective observational study including patients treated by PRP injections for knee osteoarthritis, from a university hospital. The PRP was leukocyte-poor, obtained by an ARTHREX kit, and was injected twice, at one-month intervals. They were assessed at 4 months (M4) and 7 months (M7) after the first injection. Pains on a Visual Analog Scale (VAS) and function with Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Knee injury and Osteoarthritis Outcome Score (KOOS) – Physical Function Shortform (KOOS-PS) were collected. Patients were then classified as responders if they met the OMERACT-OARSI criteria at M7. Univariate and multivariate analysis was performed to compare the two groups.

Results

Among 197 patients, 210 knees were treated. The mean age was 59.8±10.8 years, Body mass index (BMI) was 31.0±6.5. Patellofemoral osteoarthritis was found in 34.3% of the patients, the distribution according to Kellgren and Lawrence stages I, II, III, IV was 11.8%, 33.5%, 40.4% and 14.3% respectively. A majority of patients had failed viscosupplementation (62.4%). At 7 months, 43.8% were classified as responders. Total WOMAC was 49.4±16.1 at M0, 43.6±17.9 at M1, 31.1±19.0 at M4 and 31.9±19.8 at M7, with significant improvement at M4 and M7 versus baseline (p<0.0001). The VAS was 58.5±19.7, 51.6±21.7, 43.7±23.2 and 43.5±23.5 at M0, M1, M4 and M7 respectively (p<0.0001 at all 3 times versus baseline). Regarding treatment satisfaction, 70% of patients considered the treatment effective or very effective at M7. Physical therapy and a heel-buttock distance greater than 35 centimeters were the two criteria associated with a poorer response at M7 on multivariate analysis. The pain VAS at M7 appeared to be lower in patients whose osteoarthritis had been evolving for less than 24 months. Tolerance was good. There was an increase in joint effusions between M0 and M1 (17% vs. 41%, p<0.0001), but no increase in pain.

Conclusion

PRP treatment in knee osteoarthrisis appeared to be effective and well tolerated, and this response was not associated with the radiographic stage or the type of knee osteoarthritis. In accordance with the recommendations of a group of French experts, this treatment should be proposed in case of failure of drug and rehabilitation treatment, at the same level as hyaluronic acid injections.

References

[1]Jordan KM et al. EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis. déc 2003;62(12):1145‑55.

[2]Bannuru RR et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthr. Cartil. nov 2019;27(11):1578‑89.

Disclosure of Interests

None declared

Impact of Pharmacists-Led Interventions in Primary Care for Adults with Type 2 Diabetes on HbA1c Levels: A Systematic Review and Meta-Analysis

Type 2 diabetes mellitus (T2D) is responsible for an important premature mortality. Pharmacists involved in community-based pharmaceutical care services could help patients with diabetes through education and management as they participate in their regular and long-term care. This meta-analysis aimed to evaluate the association between interventions led by pharmacists in the primary care setting and mean change in HbA1c levels. Randomized controlled trials and quasi-experimental studies with a control group were included. Standardized mean differences (SMD) and their 95% confidence intervals (95% CI) were calculated to compare the mean change in HbA1c values between baseline and end of the intervention in each group. Subgroup analyses were performed to explore heterogeneity. Twelve articles were included. The results showed that pharmacist’s interventions significantly reduced HbA1c compared to usual care with an overall SMD of −0.67 (95% CI = [−0.87; −0.48], p < 0.0001). Even if no significant difference between subgroups were found, the reduction of HbA1c seemed more important when baseline HbA1c was ≥8.5%, the intervention occurred monthly, in a primary care center and in countries with a lower human development index. Our results suggest that pharmacists-led interventions in the primary care setting can improve glycemic control for adults with T2D.

A prognostic index predicting survival in transformed Waldenström macroglobulinemia

Histological transformation into diffuse large B-cell lymphoma is a rare complication in patients with Waldenström macroglobulinemia (WM) and is usually associated with a poor prognosis. The objective of this study was to develop and validate a prognostic index for survival of patients with transformed WM. Through this multicenter, international collaborative effort, we developed a scoring system based on data from 133 patients with transformed WM who were evaluated between 1995 and 2016 (training cohort). Univariate and multivariate analyses were used to propose a prognostic index with 2-year survival after transformation as an endpoint. For external validation, a dataset of 67 patients was used to evaluate the performance of the model (validation cohort). By multivariate analysis, three adverse covariates were identified as independent predictors of 2-year survival after transformation: elevated serum lactate dehydrogenase (2 points), platelet count <100x109/L (1 point) and any previous treatment for WM (1 point). Three risk groups were defined: low-risk (0-1 point, 24% of patients), intermediate-risk (2-3 points, 59%; hazard ratio = 3.4) and high-risk (4 points, 17%; hazard ratio = 7.5). Two-year survival rates were 81%, 47%, and 21%, respectively (P<0.0001). This model appeared to be a better discriminant than either the International Prognostic Index or the revised International Prognostic Index. We validated this model in an independent cohort. This easy-to-compute scoring index is a robust tool that may allow identification of groups of transformed WM patients with different outcomes and could be used for improving the development of risk-adapted treatment strategies.

The ROX index as a predictor of standard oxygen therapy outcomes in thoracic trauma

BACKGROUND

Thoracic trauma is commonplace and accounts for 50-70% of the injuries found in severe trauma. Little information is available in the literature as to timing of endotracheal intubation. The main objective of this study was to assess the accuracy of the ROX index in predicting successful standard oxygen (SO) therapy outcomes, and in pre-empting intubation.

METHODS

Patient selection included all thoracic trauma patients treated with standard oxygen who were admitted to a Level I trauma center between January 1, 2013 and April 30, 2020. Successful standard SO outcomes were defined as non-requirement of invasive mechanical ventilation within the 7 first days after thoracic trauma.

RESULTS

One hundred seventy one patients were studied, 49 of whom required endotracheal intubation for acute respiratory distress (28.6%). A ROX index score ≤ 12.85 yielded an area under the ROC curve of 0.88 with a 95% CI [0.80-0.94], 81.63sensitivity, 95%CI [0.69-0.91] and 88.52 specificity, 95%CI [0.82-0.94] involving a Youden index of 0.70. Patients with a median ROX index greater than 12.85 within the initial 24 h were less likely to require mechanical ventilation within the initial 7 days of thoracic trauma.

CONCLUSION

We have shown that a ROX index greater than 12.85 at 24 h was linked to successful standard oxygen therapy outcomes in critical thoracic trauma patients. It is our belief that an early low ROX index in the initial phase of trauma should heighten vigilance on the part of the attending intensivist, who has a duty to optimize management.

Diagnosis of postoperative recurrence of Crohn disease with MR-enterography: Value of diffusion-weighted imaging

PURPOSE

To compare the diagnostic capabilities of MR enterography (MRE) using contrast-enhanced (CE) sequences with those of MRE using diffusion-weighted (DW) imaging for the diagnosis of postoperative recurrence at the neo-terminal ileum and/or anastomosis after ileocolonic resection in patients with Crohn disease (CD), and to clarify the role of additional DW imaging to CE-MRE in this context.

MATERIAL AND METHODS

Forty patients who underwent ileal resection for CD, and both endoscopy and MRE within the first year after surgery were included. There were 21 men and 19 women, with a mean age of 38 years±12 (SD) years (range: 18-67 years). MRE examinations were blindly analyzed independently by one senior (R1) and one junior (R2) radiologist for the presence of small bowel postoperative recurrence at the anastomotic site. During a first reading session, T2-, steady-state- and DW-MRE were reviewed (DW-MRE or set 1). During a separate distant session, T2-, steady-state- and CE-MRE were reviewed (CE-MRE or set 2). Lastly, all sequences were analyzed altogether (set 3). Performances of each reader for the diagnosis of postoperative recurrence were evaluated using endoscopic findings as the standard of reference (Rutgeerts score≥i2b).

RESULTS

Fifteen patients out of 40 (37.5%) had endoscopic postoperative recurrence at the anastomotic site. Sensitivity for the diagnosis of postoperative recurrence was 73% (95% CI: 51-96%) for R1 and 67% (95% CI: 43-91%) for R2 using set 1, and 80% (95% CI: 60-100%) for both readers using set 2. There was no significant differences in sensitivity between reading set 1 and reading set 2, for either R1 or R2 (R1, P> 0.99; R2, P=0.48). Specificity was 96% (95% CI: 88-100%) for both readers using set 1 or using set 2. Reading set 3 yielded an area under the ROC curve (AUC) of 0.93 (95% CI: 0.84-1) versus 0.89 (95% CI: 0.75-1) with set 1 (P=0.18) and versus 0.89 (95% CI: 0.78-1) with set 2 (P=0.21). No significant differences in AUC were found between set 1 or 2 and set 3 (P=0.18), nor between set 1 and 2 (P=0.76). Accuracies were 88% (95% CI: 74-95%) and 85% (95% CI: 71-93%) for DW-MRE for R1 and R2, respectively; 90% (95% CI: 77-96%) for CE-MRE for both readers; and 93% (95% CI: 80-97%) and 88% (95% CI: 74-95%) for R1 and R2 with set 3, respectively.

CONCLUSION

DW-MRE has diagnostic capabilities similar to those of CE-MRE for the diagnosis of postoperative recurrence of CD at the anastomotic site.

POS0045 LEAST SIGNIFICANT CHANGE IN BONE DENSITOMETRY IN PATIENTS WITH OBESITY

Background:

Dual energy X-ray absoprtiometry is the reference method to mesure bone mineral density (1). Loss of bone mineral density is significant if it exceeds the least significant change. The threshold value used in general population is 0,03 g/cm2 (2). Patients with obesity are known for having a higher bone mineral density due to metabolism and physiopathology characteristics (3,4).

Objectives:

The aim of our study was to determine the least significant change in bone densitometry in patients with obesity.

Methods:

We conducted an interventionnal study in 120 patients with obesity who performed a bone densitometry. We measured twice the bone mineral density at the lumbar spine, the femoral neck and the total hip in the same time (5,6). We determined the least significant change in bone densitometry from each pair of measurements, using the Bland and Altman method. We also determined the least significant change in bone densitometry according to each stage of obesity.

Results:

The least significant change in bone densitometry in patients with obesity is 0,046g/cm2 at the lumbar spine, 0.069 g/cm2 at the femoral neck and 0.06 g/cm2 at the total hip.

Conclusion:

The least significant change in bone densitometry in patients with obesity is higher than in general population. These results may improve DXA interpretation in this specific population, and may personnalize their medical care.

References:

[1]Lees B, Stevenson JC. An evaluation of dual-energy X-ray absorptiometry and comparison with dual-photon absorptiometry. Osteoporos Int. mai 1992;2(3):146-52.

[2]Briot K, Roux C, Thomas T, Blain H, Buchon D, Chapurlat R, et al. Actualisation 2018 des recommandations françaises du traitement de l’ostéoporose post-ménopausique. Rev Rhum. oct 2018;85(5):428-40.

[3]Shapses SA, Pop LC, Wang Y. Obesity is a concern for bone health with aging. Nutr Res N Y N. mars 2017;39:1-13.

[4]Savvidis C, Tournis S, Dede AD. Obesity and bone metabolism. Hormones. juin 2018;17(2):205-17.

[5]Roux C, Garnero P, Thomas T, Sabatier J-P, Orcel P, Audran M, et al. Recommendations for monitoring antiresorptive therapies in postmenopausal osteoporosis. Jt Bone Spine Rev Rhum. janv 2005;72(1):26-31.

[6]Ravaud P, Reny JL, Giraudeau B, Porcher R, Dougados M, Roux C. Individual smallest detectable difference in bone mineral density measurements. J Bone Miner Res. août 1999;14(8):1449-56.

Disclosure of Interests:

None declared.

Excess Soluble fms-like Tyrosine Kinase 1 Correlates With Endothelial Dysfunction and Organ Failure in Critically Ill Coronavirus Disease 2019 Patients

Excess soluble fms-like tyrosine kinase 1 (sFlt-1), a soluble inhibitor of vascular endothelial growth factor pathway, has been demonstrated to promote endothelial dysfunction. Here, we demonstrate that sFlt-1 plasma levels correlate with respiratory symptom severity, expression of endothelial dysfunction biomarker, and incidence of organ failure in coronavirus disease 2019 patients. Clinical Trials Registration: NCT04394195.

Acquired decrease of the C3b/C4b receptor (CR1, CD35) and increased C4d deposits on erythrocytes from ICU COVID-19 patients

In order to study the mechanisms of COVID-19 damage following the complement activation phase occurring during the innate immune response to SARS-CoV-2, CR1 (the regulating complement activation factor, CD35, the C3b/C4b receptor), C4d deposits on Erythrocytes (E), and the products of complement activation C3b/C3bi, were assessed in 52 COVID-19 patients undergoing O₂ therapy or assisted ventilation in ICU units in Rheims France. An acquired decrease of CR1 density on E from COVID-19 patients was observed (Mean = 418, SD = 162, N = 52) versus healthy individuals (Mean = 592, SD = 287, N = 400), Student’s t-test p < 10⁻⁶, particularly among fatal cases, and in parallel with several parameters of clinical severity. Large deposits of C4d on E in patients were well above values observed in normal individuals, mostly without concomitant C3 deposits, in more than 80% of the patients. This finding is reminiscent of the increased C4d deposits on E previously observed to correlate with sub endothelial pericapillary deposits in organ transplant rejection, and with clinical SLE flares. Conversely, significant C3 deposits on E were only observed among ¼ of the patients. The decrease of CR1/E density, deposits of C4 fragments on E and previously reported detection of virus spikes or C3 on E among COVID-19 patients, suggest that the handling and clearance of immune complex or complement fragment coated cell debris may play an important role in the pathophysiology of SARS-CoV-2. Measurement of C4d deposits on E might represent a surrogate marker for assessing inflammation and complement activation occurring in organ capillaries and CR1/E decrease might represent a cumulative index of complement activation in COVID-19 patients.

Taken together, these original findings highlight the participation of complement regulatory proteins and indicate that E are important in immune pathophysiology of COVID-19 patients. Besides a potential role for monitoring the course of disease, these observations suggest that novel therapies such as the use of CR1, or CR1-like molecules, in order to down regulate complement activation and inflammation, should be considered.

Lack of admission biomarkers' clinical utility in outcomes prediction in patients suspected with infection in the emergency department

INTRODUCTION

Initial procalcitonin (PCT) levels may fail in mortality and septic shock prediction and raise cost-effectiveness issues. Since measurement of lactate, C-reactive protein (CRP), white blood cells and neutrophils is common in the emergency department (ED), we compared prediction abilities of these biomarkers to PCT.

METHODS

From January 1st to December 31st, 2018, an observational, single center, retrospective study was conducted in the adult ED of the Reims University Hospital (France). Endpoints were bacteremia, septic shock, and in-hospital mortality, related to the same ED visit.

RESULTS

Over one year, 459 patients suspected with infection were included, of mean age 60.4 years (SD: 22.0), with 50.8% male, and 364 (79.3%) were hospitalized following ED visit. Overall, 45 (9.8%) patients had a bacteremia, 39 (8.5%) a septic shock and 54 (11.8%) died during their hospitalization. PCT and CRP showed the best discrimination for bacteremia, with an area under curve (AUC) of 0.68 for PCT and 0.65 for CRP. PCT and lactate showed similar good discriminative power for septic shock, with an AUC of 0.78 for both, and poor discrimination for in-hospital mortality, with an AUC of 0.62 for PCT and 0.69 for lactate. Systolic blood pressure and pulse oximetry showed similar discrimination for septic shock as PCT or lactate, while they showed higher discrimination for in-hospital mortality than PCT.

CONCLUSION

Usual admission biomarkers lack clinical utility in predicting septic shock or in-hospital mortality. CRP and PCT are poorly efficient in predicting bacteremia.

Adaptation of WHO Definitions of Clinical Forms of Chikungunya Virus Infection for the Elderly

The WHO defined three clinical forms for chikungunya virus infection (CHIKV, namely, acute, atypical, and severe cases) and a chronic form. These definitions seemed inappropriate for the elderly. So, we propose an adapted definition for elderly people. A cross-sectional analysis was performed including patients aged ≥ 65 years, who attended the emergency department with a positive biological diagnosis of CHIKV in 2014. A total of 267 elderly patients (80 ± 8 years) were included. When using the 2015 WHO definitions, 114 patients could not be classified (42.7%) in any of the category, of whom 43 (37.7%) reported absence of fever, 85 (74.6%) reported absence of joint pain, and 14 (12.3%) reported absence of both fever and joint pain. After adaptation of the WHO definitions, the 114 unclassifiable patients were reclassified as follows: eight as typical cases, 50 as atypical cases, 42 as severe cases, and 14 remained unclassifiable. The atypical clinical form was the most common form. The 2015 WHO definitions of the clinical forms at the acute phase of CHIKV are ill suited to the elderly. The adapted definition we propose here appears to be more appropriate and could help improved management of older patients with CHIKV.

Optic Nerve and Perioptic Sheath Diameter (ONSD), Eyeball Transverse Diameter (ETD) and ONSD/ETD Ratio on MRI in Large Middle Cerebral Artery Infarcts: A Case-Control Study

BACKGROUND

Despite recent progress in the multidisciplinary management of large middle cerebral artery infarcts, the neurological prognosis remains worrying in a non-negligible number of cases. The objective of this study is to analyze the contribution of optic nerve and perioptic sheath measurement on MRI to the acute phase of large middle cerebral artery infarcts.

METHODS

A retrospective case-control study between January 2008 and December 2019 in a single academic medical center was performed. Cases and controls were selected by interrogation of International Classification of Diseases (ICD), 10th edition, with ischemic stroke as criterion (code I64). Decompressive hemicraniectomy was a criterion for large middle cerebral artery infarcts (cases). Cases were matched with controls (1:3) based on age (± 5 years), sex, and year of hospitalization (± 2 years) The examinations were performed on 3T MRI (Siemens IRM 3T Magnetom).Optic nerve and perioptic sheath diameter was calculated using electronic calipers, 3 mm behind retina and in a perpendicular vector with reference to the orbit in axial 3D TOF sequence.

RESULTS

Of 2612 patients, 22 patients met all the criteria of large middle cerebral artery infarcts and they were paired with 44 controls. Patients were mainly women, mean age of 53.6 years. There is a significant difference in the size of the optic nerve and perioptic sheath diameter measured on MRI at patient's admission (right: 5.13 ± 0.2 mm vs. 4.80 mm ± 0.18, p <0. 0001, left: 5.16 ± 0.17 vs 4.78 ± 0.20, p<0.0001). The AUC of optic nerve and perioptic sheath diameter was 0.93 (95%IC [0.85-1.00]), for a threshold at 5.03 mm, the sensitivity was 0.82 (95%IC [0.6-0.93]), specificity 0.94 (95%IC [0.85-0.98]). The Odds Ratio of large middle cerebral artery infarcts was 46.4 for optic nerve and perioptic sheath diameter the (95%IC [6.15-350.1] p=0.0002).

CONCLUSION

Optic nerve and perioptic sheath diameter in the first MRI can predict the risk of developing large middle cerebral artery infarcts requiring a decompressive hemicraniectomy.

COVID-19: A qualitative chest CT model to identify severe form of the disease

•

Chest CT helps identify patients with severe COVID-19 using only three qualitative features.

•

A qualitative model based on three qualitative variables can avoid calculating semi-quantitative total CT score.

•

New Early Warning Score 2 is comparable to the CT score for identification of severe forms of COVID-19.

Purpose

The purpose of this study was to identify clinical and chest computed tomography (CT) features associated with a severe form of coronavirus disease 2019 (COVID-19) and to propose a quick and easy to use model to identify patients at risk of a severe form.

Materials and methods

A total of 158 patients with biologically confirmed COVID-19 who underwent a chest CT after the onset of the symptoms were included. There were 84 men and 74 women with a mean age of 68 ± 14 (SD) years (range: 24–96 years). There were 100 non-severe and 58 severe cases. Their clinical data were recorded and the first chest CT examination was reviewed using a computerized standardized report. Univariate and multivariate analyses were performed in order to identify the risk factors associated with disease severity. Two models were built: one was based only on qualitative CT features and the other one included a semi-quantitative total CT score to replace the variable representing the extent of the disease. Areas under the ROC curves (AUC) of the two models were compared with DeLong's method.

Results

Central involvement of lung parenchyma (P < 0.001), area of consolidation (P < 0.008), air bronchogram sign (P < 0.001), bronchiectasis (P < 0.001), traction bronchiectasis (P < 0.011), pleural effusion (P < 0.026), large involvement of either one of the upper lobes or of the middle lobe (P < 0.001) and total CT score ≥ 15 (P < 0.001) were more often observed in the severe group than in the non-severe group. No significant differences were found between the qualitative model (large involvement of either upper lobes or middle lobe [odd ratio (OR) = 2.473], central involvement [OR = 2.760], pleural effusion [OR = 2.699]) and the semi-quantitative model (total CT score ≥ 15 [OR = 3.342], central involvement [OR = 2.344], pleural effusion [OR = 2.754]) with AUC of 0.722 (95% CI: 0.638–0.806) vs. 0.739 (95% CI: 0.656–0.823), respectively (P = 0.209).

Conclusion

We have developed a new qualitative chest CT-based multivariate model that provides independent risk factors associated with severe form of COVID-19.

Use of BRASS in sedated critically-ill patients as a predictable mortality factor: BRASS-ICU

Objectives: To demonstrate that a BRASS score≥ 3 at admission of intubated, ventilated and sedated patients is predictive of mortalityMethods: we have realized an Observational prospective multicenter study.All Major patients without neurological history, admitted to ICU for a non-neurological cause, sedated and admitted under mechanical ventilation were included.Results: One hundred and ten patients were included, the BRASS score as well as the FOUR and RASS scores were collected.At day 28, patients with a BRASS score ≥ 3 had an excess mortality (OR 3.29 - CI 95% [1.42-7.63], p = 0.005) as well as day 90 (OR 2.65 - CI 95% [1.19-5.88], p = 0.02), without impact on the delirium measured by CAM-ICU (OR 1.8 - CI 95% [0.68-4.77], p = 0.023). After adjustment with SAPS II, FOUR and RASS, difference in mortality was not any more different.It is also noted that patients with BRASS ≥ 3 are more sedated (RASS: -5 [-5 - -5] vs -4 [-5 - -3], p < 0.0001) and more comatose (FOUR: 2 [1-4] vs 6 [4-9], p < 0.0001), and have higher doses of midazolam (10 mg/h [5-15] vs 7.5 mg/h [5-10], p = 0.02) and sufentanil (20 μg/h [15-22.5] vs 10 [10-12.5], p = 0.01).Conclusions: The early alteration of brainstem reflexes measured by the BRASS score was not independently predictable in terms of mortality in the non-neurological ICU patients, admitted under sedation and mechanical ventilation.Trial registration: ClinicalTrials.gov Identifier: NCT03835091,Registered 8 February 2019 - prospectively registered, https://clinicaltrials.gov/ct2/show/NCT03835091.

Identification of the Factors Associated With Intraperitoneal Pressure in ADPKD Patients Treated With Peritoneal Dialysis

Introduction

Peritoneal dialysis (PD) is reported to be underused in the autosomal dominant polycystic kidney disease (ADPKD) population because doctors fear technical failure caused by reduced abdominal space and high intraperitoneal pressure (IPP).

Methods

We designed a multicenter retrospective study to be carried out in 15 French centers recruiting 60 patients with ADPKD treated with PD to identify factors associated with IPP. Inclusion criteria were start of PD between 2010 and 2017, available tomodensitometry, and IPP measurement in the first year of dialysis. The clinical and radiological data for each patient were reviewed by the same operator. Total kidney volume (TKV), liver volume, and the volume of the abdominal cavity were measured using contouring.

Results

TKV and the volume of the abdominal cavity in women and men were, respectively, 2397 ml versus 3758 ml and 9402 ml versus 12,920 ml. In the univariate analysis, IPP was significantly and positively associated with body surface area (P = 0.0024), body mass index (BMI) (P < 0.0001), the volume of the abdominal cavity (P = 0.0005), and the volume of the dialysate infused in the peritoneal cavity (IPV) (P = 0.0108). In the multivariate analysis, only BMI was still significantly associated with IPP (P = 0.0004)

Conclusions

Our results identified BMI as the main factor linked to IPP in patients with ADPKD. Despite a reliable assessment of the volume of their organs we did not find any correlation between liver and kidney volumes and IPP. To our knowledge, this is the first study designed to identify factors associated with IPP in patients with ADPKD on PD.

Is Chikungunya Virus Infection an Independent Risk Factor for 2-Year Mortality in Older Afro-Caribbean Subjects?

Purpose

The aim of this study was to investigate whether Chikungunya virus infection (CVI) was an independent risk factor for 2-year mortality in Afro-Caribbean subjects aged 65 years or older.

Patients and methods

A retrospective cohort study was performed from January 2014 to December 2016 in the University Hospital of Martinique. Subjects aged ≥65 years admitted to the hospital were included. Baseline characteristics and concurrent manifestations at admission were collected. Subjects were followed up by phone for 2 years.

Results

A total of 687 old Afro-Caribbean subjects (80.4±8.0 years) were included: 467 positive for CVI (Chik+) and 220 negative for CVI (Chik-). During the follow-up, 180 (26.2%) died. The proportion of deaths was higher among Chik- (40.9%) than among Chik+ subjects (21.6%) (p<0.0001). By multivariable analysis, when adjusted for age polyarthralgia, neurological troubles, cardiovascular disorders, absence of neutrophilia, thrombocytopenia, hypernatremia, and hospital stay, Chik+ subjects had significantly higher survival rates (HR: 0.58; 95% CI: 0.40-0.85) than Chik- ones.

Conclusion

Within the two years following hospital admission of subjects aged ≥65 years or older, Chik+ subjects had significantly higher survival rates than Chik- ones.

Corticosteroid therapy for patients with COVID-19 pneumonia: a before-after study

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Severe COVID-19 patients present overwhelming inflammatory reactions leading to lung injury.

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Corticosteroids may beneficially modulate the host immune response to COVID-19 pneumonia.

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Before–after study evaluating the effect of corticosteroid addition to COVID-19 pneumonia treatment on hospital mortality.

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In multivariate analysis, the ‘after’ period was associated with an adjusted lower risk of death (aHR = 0.47; P = 0.04).

•

‘After’ period was also associated with lower risk of ICU admission or death before ICU admission (aHR = 0.37; P < 0.001).

Anti-inflammatory drugs such as corticosteroids may beneficially modulate the host inflammatory response to coronavirus disease 2019 (COVID-19) pneumonia. The aim of this study was to evaluate the impact of addition of corticosteroids to the hospital protocol for treatment of suspected or confirmed COVID-19 pneumonia on rates of death or intensive care unit (ICU) admission. A before–after study was performed to evaluate the effect of addition of corticosteroids to our institution's COVID-19 treatment protocol on hospital mortality. A total of 257 patients with a COVID-19 diagnosis were included in this study between 3 March 2020 and 14 April 2020. As corticosteroids were widely used after 27 March 2020, two periods were considered for the purposes of this study: the ‘before’ period from 3–20 March 2020 (n = 85); and the ‘after’ period from 26 March–14 April 2020 (n = 172). The ‘after’ period was associated with a lower risk of death [adjusted hazard ratio (aHR) = 0.47, 95% confidence interval (CI) 0.23–0.97; P = 0.04] and a lower risk of ICU admission or of death before ICU admission (aHR = 0.37, 95% CI 0.21–0.64; P = 0.0005) by multivariate analysis adjusted for age, National Early Warning score and institutionalisation status. In conclusion, addition of corticosteroids to our institution's COVID-19 treatment protocol was associated with a significant reduction in hospital mortality in the ‘after’ period.

Effect of high-intensity interval training and continuous endurance training on peak oxygen uptake among seniors aged 65 or older: A meta-analysis of randomized controlled trials

BACKGROUND

Ageing is intrinsically associated with a progressive decline in cardiorespiratory fitness (CRF) as measured by peak oxygen uptake (VO_2peak ). Improving CRF through physical activity contribute to better and healthy ageing. High-intensity interval training (HIIT) is a potent method of improving CRF among seniors, yet comparisons between this type of training and traditional endurance training (ET) are equivocal especially among older adults.

PURPOSE

To analyse the effects of HIIT and ET on the VO_2peak of seniors aged 65 years or older when compared with controls and also when the two types of training were compared with one another.

METHODS

A comprehensive, systematic database search for manuscripts was performed in Embase, Medline, PubMed Central, ScienceDirect, Scopus and Web of Science using key words. Two reviewers independently assessed interventional studies for potential inclusion. Fifteen randomized controlled trials (RCTs) were included totalling 480 seniors aged 65 years or over. Across the trials, no high risk of bias was measured.

RESULTS

In pooled analysis of the RCTs, the VO_2peak was significantly higher after ET sessions compared with controls (mean difference-MD = 1.35; 95% confidence interval-CI: 0.73-1.96). Furthermore, VO_2peak was found significantly higher not only when compared HIIT with controls (MD = 4.61; 95% CI: 3.21-6.01), but also when compared HIIT with ET (MD = 3.76; 95% CI: 2.96-4.56).

CONCLUSION

High-intensity interval training and ET both elicit large improvements in the VO_2peak of older adults aged 65 or over. When compared with ET, the gain in VO_2peak was greater following HIIT. Nevertheless, further RCTs are therefore needed to confirm our results in senior's population.

Hypercalcemia at diagnosis of diffuse large B-cell lymphoma is not uncommon and is associated with high-risk features and a short diagnosis-to-treatment interval

Diffuse large B-cell lymphoma (DLBCL) is an aggressive type of non-Hodgkin lymphoma. The prevalence of hypercalcemia in this neoplasm and its prognostic significance is unclear. We retrospectively evaluated the prevalence of hypercalcemia at diagnosis of DLBCL and explored associations of hypercalcemia with clinical factors and outcome. Outcome was assessed using event-free survival at 24 months (EFS24). A total of 305 patients (248 de novo DLBCL and 57 transformed indolent lymphomas) diagnosed between 2006 and 2018 in Reims were analyzed. The prevalence of calcemia >10.5 mg/dL at diagnosis of de novo DLBCL and transformed indolent lymphomas was 23% and 26%, respectively. Hypercalcemia in de novo DLBCL was strongly associated with high-risk features, especially with International Prognostic Index (IPI) components, but also with B symptoms, β2-microglobulin, hemoglobin, and albumin levels. The diagnosis-to-treatment interval was significantly shorter for hypercalcemic patients (P = .001). These associations with adverse prognostic factors translated into lower rates of EFS24 (HR = 1.66; 95% CI, 1.08-2.54) and shorter PFS (P = .0059) and OS (P = .0003) for patients with lymphoma-related hypercalcemia but not independently of IPI parameters. These data suggest that hypercalcemia is rather a biomarker of the underlying biological aggressiveness of DLBCL.

Unilateral nephrectomy versus renal arterial embolization and technique survival in peritoneal dialysis patients with autosomal dominant polycystic kidney disease

BACKGROUND

Autosomal dominant polycystic kidney disease (ADPKD) is a common genetic disorder associated with progressive enlargement of the kidneys and liver. ADPKD patients may require renal volume reduction, especially before renal transplantation. The standard treatment is unilateral nephrectomy. However, surgery incurs a risk of blood transfusion and alloimmunization. Furthermore, when patients are treated with peritoneal dialysis (PD), surgery is associated with an increased risk of temporary or definitive switch to haemodialysis (HD). Unilateral renal arterial embolization can be used as an alternative approach to nephrectomy.

METHODS

We performed a multicentre retrospective study to compare the technique of survival of PD after transcatheter renal artery embolization with that of nephrectomy in an ADPKD population. We included ADPKD patients treated with PD submitted to renal volume reduction by either surgery or arterial embolization. Secondary objectives were to compare the frequency and duration of a temporary switch to HD in both groups and the impact of the procedure on PD adequacy parameters.

RESULTS

More than 700 patient files from 12 centres were screened. Only 37 patients met the inclusion criteria (i.e. treated with PD at the time of renal volume reduction) and were included in the study (21 embolized and 16 nephrectomized). Permanent switch to HD was observed in 6 embolized patients (28.6%) versus 11 nephrectomized patients (68.8%) (P = 0.0001). Renal artery embolization was associated with better technique survival: subdistribution hazard ratio (SHR) 0.29 [95% confidence interval (CI) 0.12-0.75; P = 0.01]. By multivariate analysis, renal volume reduction by embolization and male gender were associated with a decreased risk of switching to HD. After embolization, a decrease in PD adequacy parameters was observed but no embolized patients required temporary HD; the duration of hospitalization was significantly lower [5 days [interquartile range (IQR) 4.0-6.0] in the embolization group versus 8.5 days (IQR 6.0-11.0) in the surgery group.

CONCLUSIONS

Transcatheter renal artery embolization yields better technique survival of PD in ADPKD patients requiring renal volume reduction.

Outcome of autosomal dominant polycystic kidney disease patients on peritoneal dialysis: a national retrospective study based on two French registries (the French Language Peritoneal Dialysis Registry and the French Renal Epidemiology and Information Network)

Background

Pathological features of autosomal dominant polycystic kidney disease (ADPKD) include enlarged kidney volume, higher frequency of digestive diverticulitis and abdominal wall hernias. Therefore, many nephrologists have concerns about the use of peritoneal dialysis (PD) in ADPKD patients. We aimed to analyse survival and technique failure in ADPKD patients treated with PD.

Methods

We conducted two retrospective studies on patients starting dialysis between 2000 and 2010. We used two French registries: the French Renal Epidemiology and Information Network (REIN) and the French language Peritoneal Dialysis Registry (RDPLF). Using the REIN registry, we compared the clinical features and outcomes of ADPKD patients on PD (n = 638) with those of ADPKD patients on haemodialysis (HD) (n = 4653); with the RDPLF registry, those same parameters were determined for ADPKD patients on PD (n = 797) and compared with those of non-ADPKD patients on PD (n = 12 059).

Results

A total of 5291 ADPKD patients and 12 059 non-ADPKD patients were included. Analysis of the REIN registry found that ADPKD patients treated with PD represented 10.91% of the ADPKD population. During the study period, PD was used for 11.2% of the non-ADPKD population. Compared with ADPKD patients on HD, ADPKD patients on PD had higher serum albumin levels (38.8 ± 5.3 versus 36.8 ± 5.7 g/dL, P < 0.0001) and were less frequently diabetic (5.31 versus 7.71%, P < 0.03). The use of PD in ADPKD patients was positively associated with the occurrence of a kidney transplantation but not with death [hazard ratio 1.15 (95% confidence interval 0.84-1.58)]. Analysis of the RDPLF registry found that compared with non-ADPKD patients on PD, ADPKD patients on PD were younger and had fewer comorbidities and better survival. ADPKD status was not associated with an increased risk of technique failure or an increased risk of peritonitis.

Conclusions

According to our results, PD is proposed to a selected population of ADPKD patients, PD does not have a negative impact on ADPKD patients' overall survival and PD technique failure is not influenced by ADPKD status. Therefore PD is a reasonable option for ADPKD patients.

In vivo efficacy of endothelial growth medium stimulated mesenchymal stem cells derived from patients with critical limb ischemia

Background

Cell therapy has been proposed for patients with critical limb ischemia (CLI). Autologous bone marrow derived cells (BMCs) have been mostly used, mesenchymal stem cells (MSCs) being an alternative. The aim of this study was to characterize two types of MSCs and evaluate their efficacy.

Methods

MSCs were obtained from CLI-patients BMCs. Stimulated- (S-) MSCs were cultured in endothelial growth medium. Cells were characterized by the expression of cell surface markers, the relative expression of 6 genes, the secretion of 10 cytokines and the ability to form vessel-like structures. The cell proangiogenic properties was analysed in vivo, in a hindlimb ischemia model. Perfusion of lower limbs and functional tests were assessed for 28 days after cell infusion. Muscle histological analysis (neoangiogenesis, arteriogenesis and muscle repair) was performed.

Results

S-MSCs can be obtained from CLI-patients BMCs. They do not express endothelial specific markers but can be distinguished from MSCs by their secretome. S-MSCs have the ability to form tube-like structures and, in vivo, to induce blood flow recovery. No amputation was observed in S-MSCs treated mice. Functional tests showed improvement in treated groups with a superiority of MSCs and S-MSCs. In muscles, CD31+ and αSMA+ labelling were the highest in S-MSCs treated mice. S-MSCs induced the highest muscle repair.

Conclusions

S-MSCs exert angiogenic potential probably mediated by a paracrine mechanism. Their administration is associated with flow recovery, limb salvage and muscle repair. The secretome from S-MSCs or secretome-derived products may have a strong potential in vessel regeneration and muscle repair.

Trial registration NCT00533104

Electronic supplementary material

The online version of this article (10.1186/s12967-019-2003-3) contains supplementary material, which is available to authorized users.

Is the Mirror Image Method Really Useful in Tumor Tissue Bank Quality Control?

Oncology research projects are highly dependent on the quality of tumor samples stored in the biobank. Microscopic control is important to ensure the quality of the frozen sample (Does the sample correspond to tumor tissue? Does the sample contain a sufficient number of tumor cells for molecular analysis?). The aim of this study was to evaluate the value of the mirror image method in quality control of colonic adenocarcinoma samples stored in a tumor bank. Microscopic concordance for the differentiation grade, malignant and normal cell percentages, necrosis, mucinous component, and ulceration was assessed on 82 colon adenocarcinoma banked samples and their paired, formalin-fixed, paraffin-embedded mirror controls. Molecular concordance for KRAS status was evaluated in 76 of these 82 cases. Morphological correspondence between frozen and mirror samples was good for the mucinous component (intraclass correlation coefficient [ICC] = 0.81), moderate for differentiation (Cohen's kappa coefficient [k] = 0.67), fair for malignant cells (ICC = 0.44), and poor for ulceration (k = 0.08), normal tissue (ICC = 0.36), and necrosis (ICC = 0.13) percentages. Molecular correspondence for KRAS status was almost perfect (95% correspondence, k = 0.88) between frozen and mirror samples. In conclusion, the mirror sample method is not a good alternative for microscopic and molecular control of frozen colonic adenocarcinoma samples.

Effectiveness of an education health programme about Middle East respiratory syndrome coronavirus tested during travel consultations

OBJECTIVE

We aimed to evaluate the level of knowledge of Middle East respiratory syndrome coronavirus (MERS-CoV) among Hajj pilgrims before and after an education health programme during international vaccine consultations in France.

STUDY DESIGN

A cross-sectional study was performed in the consultation for travel medicine and international vaccination in Reims University Hospital between July 2014 and October 2015.

METHODS

Consecutive adults (>18 years old) who attended for pre-Hajj meningococcal vaccination were eligible to complete an anonymous questionnaire with closed answers to evaluate their level of knowledge about MERS-CoV. To evaluate the effectiveness of the information given during the consultation, the same questionnaire was completed by the Hajj pilgrim before and after the consultation, where the information about MERS-CoV was provided.

RESULTS

Among 82 Hajj pilgrim adults enrolled in the study, less than 25% were aware of the routes of transmission, symptoms and preventive behaviours to adopt abroad or in case of fever. Pilgrims had a higher rate of correct responses on each question at the time they completed the second questionnaire, as compared with the first, with 11 of 13 questions answered significantly better after delivery of educational information about MERS-CoV. However, although the rate of correct answers to the questions about routes of transmission, symptoms, preventive behaviours to adopt in case of fever and time delay between return and potential MERS-CoV occurrence increased significantly after receiving the information, the rates remained below 50%.

CONCLUSION

Information given during travel consultations significantly increases the general level of knowledge, but not enough to achieve epidemic control.

Impact of the implementation of a fast-track on emergency department length of stay and quality of care indicators in the Champagne-Ardenne region: a before-after study

OBJECTIVES

We aimed to evaluate the effect of the implementation of a fast-track on emergency department (ED) length of stay (LOS) and quality of care indicators.

DESIGN

Adjusted before-after analysis.

SETTING

A large hospital in the Champagne-Ardenne region, France.

PARTICIPANTS

Patients admitted to the ED between 13 January 2015 and 13 January 2017.

INTERVENTION

Implementation of a fast-track for patients with small injuries or benign medical conditions (13 January 2016).

PRIMARY AND SECONDARY OUTCOME MEASURES

Proportion of patients with LOS ≥4 hours and proportion of access block situations (when patients cannot access an appropriate hospital bed within 8 hours). 7-day readmissions and 30-day readmissions.

RESULTS

The ED of the intervention hospital registered 53 768 stays in 2016 and 57 965 in 2017 (+7.8%). In the intervention hospital, the median LOS was 215 min before the intervention and 186 min after the intervention. The exponentiated before-after estimator for ED LOS ≥4 hours was 0.79; 95% CI 0.77 to 0.81. The exponentiated before-after estimator for access block was 1.19; 95% CI 1.13 to 1.25. There was an increase in the proportion of 30 day readmissions in the intervention hospital (from 11.4% to 12.3%). After the intervention, the proportion of patients leaving without being seen by a physician decreased from 10.0% to 5.4%.

CONCLUSIONS

The implementation of a fast-track was associated with a decrease in stays lasting ≥4 hours without a decrease in access block. Further studies are needed to evaluate the causes of variability in ED LOS and their connections to quality of care indicators.

Copper for the Prevention of Outbreaks of Health Care-Associated Infections in a Long-term Care Facility for Older Adults

OBJECTIVE

We aimed to study the efficacy of copper as an antimicrobial agent by comparing incidence rates during outbreaks in areas equipped vs not equipped with copper surfaces in a long-term facility for dependent older adults (nursing home).

DESIGN

Prospective observational pilot study in a nursing home.

SETTING AND PARTICIPANT

All persons resident in the nursing home belonging to Reims University Hospital, from February 1, 2015 to June 30, 2016, were included.

METHODS

Incidence rates for health care-related infections during outbreaks occurring during the study period were compared between the wing that was equipped and the wing that was not equipped with copper surfaces. Results are expressed as relative risks (RRs) and 95% confidence intervals (95% CIs).

RESULTS

During the study period, 556 residents were included; average age was 85.4 ± 9.2 years, and 76% were women. Four outbreaks occurred during the study period: 1 influenza, 1 keratoconjunctivitis, and 2 gastroenteritis outbreaks. The risk of hand-transmitted health care-associated infection was significantly lower in the area equipped with copper surfaces (RR 0.3, 95% CI 0.1-0.5).

CONCLUSIONS AND IMPLICATIONS

In our study, copper was shown to reduce the incidence of hand-transmitted health care-associated infections and could represent a relatively simple measure to help prevent HAIs in nursing homes.

Long-term survival and clinical forms in the acute phase of Chikungunya virus infection in older Caribbeans

OBJECTIVE

To investigate whether the long-term survival in elderly patients with prior Chikungunya virus infection (CVI) is associated with the clinical form presented in the acute phase, as defined by the WHO classification.

METHODS

Retrospective cohort study performed in Martinique University Hospitals. Patients who attended the emergency department for suspected CVI, and who had a positive biological diagnosis of CVI by reverse transcription-polymerase chain reaction on a plasma sample between 10 January and 31 December 2014 were eligible for inclusion. Time-to-death was the primary outcome. The independent relationship between clinical forms and time-to-death was analysed using a Cox model.

RESULTS

In total, 268 patients were included. Mean age was 80 ± 8 years, 53% were women. Median length of follow-up was 28 months (range: 0-39). During follow-up, 53 (19.8%) patients died. Median survival time was 13.2 months (range: 0-33.6). At the end of follow-up, death rates were 4.6% for acute clinical cases, 19.0% for atypical cases, 19.2% for severe acute cases and 23.5% for unclassifiable cases. By multivariable analysis, the clinical form of CVI at admission was found to be independently associated with long-term survival (atypical form: HR = 2.38; 95% CI = 2.15-2.62; severe acute form: HR = 2.40; 95% CI = 2.17-2.64; unclassifiable form: HR = 2.28; 95% CI = 2.06-2.51).

CONCLUSION

The clinical form at presentation with CVI has a significant impact on long-term survival. Management of CVI patients should be tailored according to their clinical form at admission.

Safety of combination therapy with two bDMARDs in patients with rheumatoid arthritis: A systematic review and meta-analysis

OBJECTIVES

We performed a systematic review and meta-analysis of the current literature to assess the safety of combining two biologic disease-modifying antirheumatic drugs (bDMARDs) in the treatment of rheumatoid arthritis (RA).

METHODS

We systematically searched for controlled studies evaluating safety in patients with RA treated with two bDMARDs independently of dose-regimen. Databases used were MEDLINE (via Pubmed), EMBase, Cochrane Library, Scopus, ClinicalTrials.gov, and the WHO International Clinical Trials Registry platform. A meta-analysis was performed between groups on combination therapy and patients on single therapy using random effects model calculating odds ratio (OR) as well as 95% confidence interval (CI). The primary outcome was the rate of serious adverse events (SAEs).

RESULTS

Six studies with a total of 623 patients (410 on combination therapy and 213 on single therapy) were included. Median follow-up was 9.5 months (range 6-12 months). There was a significant increase in SAEs in the combination group (14.9 vs 6.0%, OR 2.51, 95% CI 1.29-4.89, I² 0%) as well as in total adverse events (94.6 vs 89.1%, OR 2.07, 95% CI 1.11-3.86, I² 0%). When performing subgroup analysis in patients receiving only full-dose of both bDMARDs there was a significant increase in serious infections (6.7 vs 0.6%, OR 5.58, 95% CI 1.25-24.90, I² 0%) and the risk of SAEs remained significantly higher (17.1 vs 6.2%, OR 2.72, 95% CI 1.30-5.69, I² 0%).

CONCLUSION

Our findings suggest that combination therapy with two bDMARDs in RA appears to increase the risk of SAEs during the first twelve months of treatment.

Copper Alloy Touch Surfaces in Healthcare Facilities: An Effective Solution to Prevent Bacterial Spreading

In the healthcare environment, microorganisms' cross-transmission between inanimate surfaces and patients or healthcare workers can lead to healthcare-associated infections. A recent interest has grown to create antimicrobial copper touch surfaces, in order to counteract microbial spread in the healthcare environment. For the first time, five French long-term care facilities were at 50% fitted with copper alloys door handles and handrails. Related to the environmental bacterial contamination, 1400 samples were carried out on copper and control surfaces over three years after copper installation. In addition, some copper door handles were taken from the different facilities, and their specific activity against methicillin-resistant S. aureus (MRSA) was tested in vitro. In comparison to control surfaces, copper door handles and handrails revealed significantly lower contamination levels. This difference was observed in the five long-term care facilities and it persists through the three years of the study. High and extreme levels of bacterial contamination were less frequent on copper surfaces. Although, the antibacterial activity of copper surfaces against MRSA was lowered after three years of regular use, it was still significant as compared to inert control surfaces. Therefore, copper containing surfaces are promising actors in the non-spreading of environmental bacterial contamination in healthcare facilities.

Misdiagnosis of Chikungunya Virus Infection: Comparison of Old and Younger Adults

OBJECTIVES

To assess the frequency of diagnostic errors in older adults presenting to the emergency department (ED) with symptoms suggestive of Chikungunya virus infection (CVI) and to compare the rates of misdiagnosis of older and younger adults.

DESIGN

Cross-sectional study performed in the University Hospitals of Martinique from retrospective cases.

SETTING

Emergency department.

PARTICIPANTS

Individuals aged 65 and older who attended the ED and underwent reverse transcription polymerase chain reaction (RT-PCR) testing for CVI between January and December 2014 (n=333, mean age 80±8) were considered eligible and were compared with a randomly selected sample of younger adults (< 65) (n=143, mean age 45±13).

MEASUREMENTS

Misdiagnosis rates.

RESULTS

The rate of misdiagnosis of CVI in the ED was 30.6% in individuals aged 65 and older and 6.3% in those younger than 65 (p<.001). The overdiagnosis rate was 9.0% in individuals aged 65 and older and 3.5% in those younger than 65 (p=.04). The underdiagnosis rate was significantly higher (p<.001) in individuals aged 65 and older (21.6%) than in those younger than 65 (2.8%).

CONCLUSION

Misdiagnosis of CVI during an epidemic is statistically more frequent in older than younger adults because clinical presentation is often atypical in older adults. Specific diagnostic tools for older adults and better awareness of ED physicians of different presentations in different age groups could help to reduce the rate of misdiagnosis of CVI in the ED.