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Demina A, Desprès C, Mamzer MF. A qualitative study of professionals' perspectives on the ethics of medically-delivered safer injection education for people who inject drugs. BMC Med Ethics 2023; 24:63. [PMID: 37568123 PMCID: PMC10422818 DOI: 10.1186/s12910-023-00939-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND In this qualitative analysis we aimed to explore addiction physicians' perspectives on safer injection education for people who inject drugs, especially: (1) on possible means of introducing safer injection education in the medical environment, (2) on the compatibility of safer injection education with each physician's core values and goals, and (3) on possible reasons for the ethical dilemma in safer injection education. METHODS We conducted semi-structured interviews with eleven physicians practicing addiction medicine in France in clinical and harm reduction settings. RESULTS All participants were in favor of educational interventions for people who inject drugs. Nonetheless, these interventions varied from simple advice to injection supervision and they were seen as less acceptable when they concerned the practical and material aspects of injection. Some participants found that physicians practicing in clinical settings, where patients consult mostly to stop their drug use, should not practice safer injection education. On the contrary, other participants claimed that safer injection education was essential in all settings and was not a choice but rather a duty for addiction physicians. The ethical dilemma of such intervention when delivered by medical staff was viewed as a complex phenomenon, related to the representations of intravenous drug use and to societal expectations from physicians. CONCLUSION Physicians' views on safer injection education for people who inject drugs reveal an emotionally charged subject related to the structural organization of addiction management in France. Such education is marked by an arduous history of harm reduction policies in France. IRB REGISTRATION: #00011928.
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Affiliation(s)
- Anastasia Demina
- Addiction medicine department, CHU Dijon Bourgogne, Dijon, France.
- Université de Bourgogne, INSERM U1093 « Cognition, Action et Plasticité Sensorimotrice », Dijon, France.
- Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, Laboratoire ETREs, Inserm, Paris, F-75006, France.
| | - Caroline Desprès
- Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, Laboratoire ETREs, Inserm, Paris, F-75006, France
| | - Marie-France Mamzer
- Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, Laboratoire ETREs, Inserm, Paris, F-75006, France
- Unité Fonctionnelle d'Ethique Médicale, Hôpital Necker-Enfants malades, APHP, 149 rue de Sèvres, Paris, 75015, France
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Giabicani M, Le Terrier C, Poncet A, Guidet B, Rigaud JP, Quenot JP, Mamzer MF, Pugin J, Weiss E, Bourcier S. Limitation of life-sustaining therapies in critically ill patients with COVID-19: a descriptive epidemiological investigation from the COVID-ICU study. Crit Care 2023; 27:103. [PMID: 36906643 PMCID: PMC10006561 DOI: 10.1186/s13054-023-04349-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/06/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Limitations of life-sustaining therapies (LST) practices are frequent and vary among intensive care units (ICUs). However, scarce data were available during the COVID-19 pandemic when ICUs were under intense pressure. We aimed to investigate the prevalence, cumulative incidence, timing, modalities, and factors associated with LST decisions in critically ill COVID-19 patients. METHODS We did an ancillary analysis of the European multicentre COVID-ICU study, which collected data from 163 ICUs in France, Belgium and Switzerland. ICU load, a parameter reflecting stress on ICU capacities, was calculated at the patient level using daily ICU bed occupancy data from official country epidemiological reports. Mixed effects logistic regression was used to assess the association of variables with LST limitation decisions. RESULTS Among 4671 severe COVID-19 patients admitted from February 25 to May 4, 2020, the prevalence of in-ICU LST limitations was 14.5%, with a nearly six-fold variability between centres. Overall 28-day cumulative incidence of LST limitations was 12.4%, which occurred at a median of 8 days (3-21). Median ICU load at the patient level was 126%. Age, clinical frailty scale score, and respiratory severity were associated with LST limitations, while ICU load was not. In-ICU death occurred in 74% and 95% of patients, respectively, after LST withholding and withdrawal, while median survival time was 3 days (1-11) after LST limitations. CONCLUSIONS In this study, LST limitations frequently preceded death, with a major impact on time of death. In contrast to ICU load, older age, frailty, and the severity of respiratory failure during the first 24 h were the main factors associated with decisions of LST limitations.
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Affiliation(s)
- Mikhael Giabicani
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Paris, France.,Centre de Recherche des Cordeliers, Université Paris Cité, Inserm, Laboratoire ETREs, Sorbonne Université, Paris, France
| | - Christophe Le Terrier
- Division of Intensive Care, Geneva University Hospitals, Faculty of Medicine, University of Geneva, 4 Rue Gabrielle-Perret-Gentil, 1211, Geneva 14, Switzerland
| | - Antoine Poncet
- Clinical Research Centre, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Division of Clinical Epidemiology, Department of Health and Community Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Bertrand Guidet
- Service de Réanimation Médicale, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Paris, France
| | | | - Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - Marie-France Mamzer
- Centre de Recherche des Cordeliers, Université Paris Cité, Inserm, Laboratoire ETREs, Sorbonne Université, Paris, France.,Unité Fonctionnelle d'Ethique Médicale, Hôpital Necker-Enfants Malades, APHP, Paris, France
| | - Jérôme Pugin
- Division of Intensive Care, Geneva University Hospitals, Faculty of Medicine, University of Geneva, 4 Rue Gabrielle-Perret-Gentil, 1211, Geneva 14, Switzerland
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Paris, France
| | - Simon Bourcier
- Division of Intensive Care, Geneva University Hospitals, Faculty of Medicine, University of Geneva, 4 Rue Gabrielle-Perret-Gentil, 1211, Geneva 14, Switzerland.
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Giabicani M, Arditty L, Mamzer MF, Fournel I, Ecarnot F, Meunier-Beillard N, Bruneel F, Weiss E, Spranzi M, Rigaud JP, Quenot JP. Team-family conflicts over end-of-life decisions in ICU: A survey of French physicians' beliefs. PLoS One 2023; 18:e0284756. [PMID: 37098023 PMCID: PMC10128920 DOI: 10.1371/journal.pone.0284756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/08/2023] [Indexed: 04/26/2023] Open
Abstract
INTRODUCTION Conflicts between relatives and physicians may arise when decisions are being made about limiting life-sustaining therapies (LST). The aim of this study was to describe the motives for, and management of team-family conflicts surrounding LST limitation decisions in French adult ICUs. METHODS Between June and October 2021, French ICU physicians were invited to answer a questionnaire. The development of the questionnaire followed a validated methodology with the collaboration of consultants in clinical ethics, a sociologist, a statistician and ICU clinicians. RESULTS Among 186 physicians contacted, 160 (86%) answered all the questions. Conflicts over LST limitation decisions were mainly related to requests by relatives to continue treatments considered to be unreasonably obstinate by ICU physicians. The absence of advance directives, a lack of communication, a multitude of relatives, and religious or cultural issues were frequently mentioned as factors contributing to conflicts. Iterative interviews with relatives and proposal of psychological support were the most widely used tools in attempting to resolve conflict, while the intervention of a palliative care team, a local ethics resource or the hospital mediator were rarely solicited. In most cases, the decision was suspended at least temporarily. Possible consequences include stress and psychological exhaustion among caregivers. Improving communication and anticipation by knowing the patient's wishes would help avoid these conflicts. CONCLUSION Team-family conflicts during LST limitation decisions are mainly related to requests from relatives to continue treatments deemed unreasonable by physicians. Reflection on the role of relatives in the decision-making process seems essential for the future.
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Affiliation(s)
- Mikhael Giabicani
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, and Université Paris Cité, Paris, France
- Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Cité, Inserm, Laboratoire ETREs, Paris, France
| | - Laure Arditty
- Service de Réanimation, Centre Hospitalier Intercommunal des Alpes du Sud, Gap, France
| | - Marie-France Mamzer
- Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Cité, Inserm, Laboratoire ETREs, Paris, France
- Unité Fonctionnelle d'Ethique Médicale, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Isabelle Fournel
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Besançon, Besançon, France
- EA3920, Université de Bourgogne-Franche Comté, Besançon, France
| | - Nicolas Meunier-Beillard
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- DRCI, USMR, CHU Dijon Bourgogne, Dijon, France
| | - Fabrice Bruneel
- Intensive Care Unit, Versailles Hospital Center, Le Chesnay, France
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, and Université Paris Cité, Paris, France
| | - Marta Spranzi
- Center for Clinical Ethics, AP-HP, Paris and Université de Versailles Saint-Quentin en Yvelines, Versailles, France
| | - Jean-Philippe Rigaud
- Service de Médecine Intensive Réanimation, CH de Dieppe, Dieppe, France
- Espace de Réflexion Éthique de Normandie, CHU de Caen, Caen, France
| | - Jean-Pierre Quenot
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, Dijon, France
- Equipe Lipness, Centre de Recherche INSERM UMR1231 et LabEx LipSTIC, Université de Bourgogne-Franche Comté, Dijon, France
- Espace de Réflexion Éthique Bourgogne Franche-Comté (EREBFC), Dijon, France
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Lahmi L, Mamzer MF, Burgun A, Durdux C, Bibault JE. Ethical Aspects of Artificial Intelligence in Radiation Oncology. Semin Radiat Oncol 2022; 32:442-448. [DOI: 10.1016/j.semradonc.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Desprès C, Mamzer MF. Le consentement éclairé en question dans le cadre de collections en biobanque. Bull Cancer 2022; 109:948-959. [DOI: 10.1016/j.bulcan.2022.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 03/23/2022] [Accepted: 03/29/2022] [Indexed: 10/18/2022]
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Mamzer MF. Introduction au IIe séminaire ouvert de l’équipe « Étres » : attitudes individuelles et interrogations collectives nées de la crise sanitaire de la covid-19. Médecine Palliative 2022. [PMCID: PMC9359507 DOI: 10.1016/j.medpal.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
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Daniel C, Paris N, Pierre O, Griffon N, Breant S, Orlova N, Serre P, Leprovost D, Denglos S, Mouchet A, Dubiel J, Gozlan R, Chatellier G, Bey R, Frank M, Hassen-Khodja C, Mamzer MF, Hilka M. AP-HP Health Data Space (AHDS) to the Test of the Covid-19 Pandemic. Stud Health Technol Inform 2022; 294:28-32. [PMID: 35612010 DOI: 10.3233/shti220390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
UNLABELLED Sharing observational and interventional health data within a common data space enables university hospitals to leverage such data for biomedical discovery and moving towards a learning health system. OBJECTIVE To describe the AP-HP Health Data Space (AHDS) and the IT services supporting piloting, research, innovation and patient care. METHODS Built on three pillars - governance and ethics, technology and valorization - the AHDS and its major component, the Clinical Data Warehouse (CDW) have been developed since 2015. RESULTS The AP-HP CDW has been made available at scale to AP-HP both healthcare professionals and public or private partners in January 2017. Supported by an institutional secured and high-performance cloud and an ecosystem of tools, mostly open source, the AHDS integrates a large amount of massive healthcare data collected during care and research activities. As of December 2021, the AHDS operates the electronic data capture for almost +840 clinical trials sponsored by AP-HP, the CDW is enabling the processing of health data from more than 11 million patients and generated +200 secondary data marts from IRB authorized research projects. During the Covid-19 pandemic, AHDS has had to evolve quickly to support administrative professionals and caregivers heavily involved in the reorganization of both patient care and biomedical research. CONCLUSION The AP-HP Data Space is a key facilitator for data-driven evidence generation and making the health system more efficient and personalized.
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Affiliation(s)
- Christel Daniel
- Innovation and Data, IT Department, AP-HP, Paris, France
- LIMICS, F-75006, Paris, France
- Sorbonne Universités, Paris, France
| | - Nicolas Paris
- Innovation and Data, IT Department, AP-HP, Paris, France
| | - Olivier Pierre
- Innovation and Data, IT Department, AP-HP, Paris, France
| | - Nicolas Griffon
- Innovation and Data, IT Department, AP-HP, Paris, France
- LIMICS, F-75006, Paris, France
- Sorbonne Universités, Paris, France
| | | | - Nina Orlova
- Innovation and Data, IT Department, AP-HP, Paris, France
| | - Patricia Serre
- Innovation and Data, IT Department, AP-HP, Paris, France
| | - Damien Leprovost
- Innovation and Data, IT Department, AP-HP, Paris, France
- LIMICS, F-75006, Paris, France
- Sorbonne Universités, Paris, France
| | | | | | - Julien Dubiel
- Innovation and Data, IT Department, AP-HP, Paris, France
| | - Rafael Gozlan
- Innovation and Data, IT Department, AP-HP, Paris, France
| | | | - Romain Bey
- Innovation and Data, IT Department, AP-HP, Paris, France
| | - Marie Frank
- Department of Medical Information (DIM), Hôpitaux Universitaires Paris-Saclay, AP-HP Paris, France
| | | | | | - Martin Hilka
- Innovation and Data, IT Department, AP-HP, Paris, France
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Zarzavadjian Le Bian A, Pantel L, Tresallet C, Mamzer MF. Entropy as the main justification for research in medical ethics. Philos Ethics Humanit Med 2022; 17:9. [PMID: 35505377 PMCID: PMC9066972 DOI: 10.1186/s13010-022-00121-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 04/01/2022] [Indexed: 06/14/2023] Open
Abstract
Ethics is an unconventional field of research for a surgeon, as ethics in surgery owns several specificities and surgery is considered an aggressive specialty. Therefore, the interest of research in medical ethics is sometimes unclear.In this short essay, we discussed the interest of research in medical ethics using a comparison to thermodynamics and mainly, entropy. During the transformation of a figure from one state to another, some energy is released or absorbed; yet, a part of this energy is wasted because of "unordered" (and unsuccessful) reactions: it is Entropy.This "wasted energy" exists in Medical practice and justifies research in Medical ethics.
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Affiliation(s)
- Alban Zarzavadjian Le Bian
- Service de Chirurgie Générale et Digestive, Hôpital Louis Pasteur, Hôpitaux de Chartres, 4, rue Claude Bernard, 28630, Le Coudray, France.
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, USPC, Université Paris Descartes, Université Paris Diderot, Équipe d'accueil ETRES, Paris, France.
| | - Louis Pantel
- Service de Chirurgie Générale et Digestive, Hôpital Avicenne, Assistance Publique - Hôpitaux de Paris, Université Paris XIII, Bobigny, France
| | - Christophe Tresallet
- Service de Chirurgie Générale et Digestive, Hôpital Avicenne, Assistance Publique - Hôpitaux de Paris, Université Paris XIII, Bobigny, France
| | - Marie-France Mamzer
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, USPC, Université Paris Descartes, Université Paris Diderot, Équipe d'accueil ETRES, Paris, France
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Viallard ML, Mamzer MF, Mulliez A, Greco C. [Connaître les aspects spécifiques des soins palliatifs en pédiatrie]. Rev Prat 2022; 72:549-557. [PMID: 35899650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Marcel-Louis Viallard
- Équipe Êtres; centre de recherche des Cordeliers, université de Paris, 75006 Paris, France - Équipe de soins palliatifs pédiatriques et périnataux, Necker-Enfants malades, 75015 Paris, France
| | - Marie-France Mamzer
- Équipe Êtres; centre de recherche des Cordeliers, université de Paris, 75006 Paris, France - UF d'éthique clinique, Necker- Enfants malades, 75015 Paris, France
| | - Adèle Mulliez
- Équipe de soins palliatifs pédiatriques et périnataux, Necker-Enfants malades, 75015 Paris, France
| | - Céline Greco
- Équipe de soins palliatifs pédiatriques et périnataux, Necker-Enfants malades, 75015 Paris, France
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Chevance A, Fortel A, Jouannin A, Denis F, Mamzer MF, Ravaud P, Sidorkiewicz S. Acceptability of and Willingness to Take Digital Pills by Patients, the Public, and Health Care Professionals: Qualitative Content Analysis of a Large Online Survey. J Med Internet Res 2022; 24:e25597. [PMID: 35179509 PMCID: PMC8900921 DOI: 10.2196/25597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/11/2021] [Accepted: 08/04/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Digital pills are pills combined with a sensor, which sends a signal to a patch connected to a smartphone when the pills are ingested. Health care professionals can access patient data from digital pills online via their own interface, thus allowing them to check whether a patient took the drug. Digital pills were developed for the stated goal of improving treatment adherence. The US Food and Drug Administration approved the first digital pills in November 2017, but the manufacturer withdrew its application to the European Medicines Agency in July 2020 because of insufficient evaluation. OBJECTIVE As recommended for the evaluation of health technologies, this study assesses the prospective acceptability of and willingness to take digital pills among patients, the public, and health care professionals. METHODS Participants were patients who were receiving long-term treatment for a chronic condition, public participants (both groups recruited from a representative sample), and health care professionals. Participants answered 5 open-ended questions regarding the acceptability of digital pills and 1 close-ended question regarding the willingness to take digital pills, which were developed in a preliminary qualitative study. We explored the 5 theoretical dimensions of acceptability by performing an abductive qualitative content analysis of all free-text responses. We assessed data saturation with mathematical models. We fitted a multivariate logistic regression model to identify the sociodemographic and health characteristics associated with the willingness to take digital pills. RESULTS Between January 29, 2020, and April 18, 2020, 767 patients, 1238 public participants, and 246 health care professionals provided 11,451 free-text responses. We identified 98 codes related to the acceptability of digital pills: 29 codes on perceived clinical effectiveness (eg, sensor safety cited by 66/2251 participants, 29.5%), 6 on perceived burden (eg, increased doctors' workload, 164/2251 participants, 7.3%), 25 on perceived ethicality (eg, policing, 345/2251 participants, 15.3%), 30 codes on perceived opportunity (eg, exclusively negative perception, 690/2251 participants, 30.7%), and 8 on affective attitude (eg, anger, 541/2251, 24%). Overall, 271/767 (35.3%) patients, 376/1238 (30.4%) public participants, and 39/246 (15.8%) health care professionals reported willingness to take digital pills. This willingness was associated with male sex (odds ratio 1.98, 95% CI 1.62-2.43) and current use of a connected device to record health settings (with a dose-response relationship). CONCLUSIONS The prospective acceptability of and willingness to take digital pills were limited by clinical and ethical concerns both at the individual and societal level. Our results suggest that digital pills should not be considered a mere change in the form of drug administration but a complex intervention requiring specific evaluation before extended use in clinical routine practice as well as an ethical and legal framework to ensure safe and ethical collection and use of health data through a patient-centered approach.
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Affiliation(s)
- Astrid Chevance
- Center for Research in Epidemiology and Statistics, Université de Paris-French National Institute for Health and Medical Research, Paris, France.,Service d'épidémiologie clinique, Hôpital Hôtel Dieu, Assistance Publique- Hôpitaux de Paris, Paris, France
| | - Axel Fortel
- Faculté de médecine de Créteil, Université Paris-Est-Créteil, Créteil, France
| | - Adeline Jouannin
- Département de Médecine Générale, Université de Rennes, Rennes, France.,Centre d'investigation clinique de Rennes, Centre Hospitalo-Universitaire de Rennes, Université de Rennes-French National Institute for Health and Medical Research, Rennes, France.,Department of Ethics, Research, Translations, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, French National Institute for Health and Medical Research, Paris, France
| | - Faustine Denis
- Department of Psychiatry, Groupe Hospitalo-Universitaire Paris Psychiatrie Neurosciences, Paris, France
| | - Marie-France Mamzer
- Department of Ethics, Research, Translations, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, French National Institute for Health and Medical Research, Paris, France.,Medical ethics Unit, Hôpital Necker Enfants-Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Philippe Ravaud
- Center for Research in Epidemiology and Statistics, Université de Paris-French National Institute for Health and Medical Research, Paris, France.,Service d'épidémiologie clinique, Hôpital Hôtel Dieu, Assistance Publique- Hôpitaux de Paris, Paris, France.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States
| | - Stephanie Sidorkiewicz
- Center for Research in Epidemiology and Statistics, Université de Paris-French National Institute for Health and Medical Research, Paris, France.,Département de Médecine Générale, Université de Paris-French National Institute for Health and Medical Research, Paris, France
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Ricadat É, Béliard A, Citrini M, Craus Y, Gabarro C, Mamzer MF, Marques A, Sannié T, Teixeira M, Tocilovac M, Velpry L, Villa F, Virole L, Lefève C. COVID-19 Health Crisis and Chronic Illness: Protocol for a Qualitative Study. JMIR Res Protoc 2021; 10:e28728. [PMID: 34460413 PMCID: PMC8432515 DOI: 10.2196/28728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/19/2021] [Accepted: 04/19/2021] [Indexed: 11/22/2022] Open
Abstract
Background The acute nature of the COVID-19 pandemic has put a strain on health resources that are usually dedicated to chronic illnesses. Resulting changes in care practices and networks have had major repercussions on the experience of people with chronic disorders. Objective This paper presents the protocol of the Parcours, Associations, Réseau, Chronicité, Organisation, Usagers, Retour d’expérience, Soins (PARCOURS)-COVID study. The aim of this study is to evaluate the effects of reorganization of the health system on the usual care network of patients with chronic illness, which fosters and qualifies the quality and continuum of care provided. The first objective of this study is to document these patients’ experiences through transformations and adaptations of their network, both in the practical dimension (ie, daily life and care) and subjective dimension (ie, psychosocial experience of illness and relationship to the health system). The second objective of the study is to understand and acknowledge these reorganizations during the COVID-19 lockdown and postlockdown periods. The third objective is to produce better adapted recommendations for patients with chronic illness and value their experience for the management of future health crisis. Methods The PARCOURS-COVID study is a qualitative and participatory research involving patient organizations as research partners and members of these organizations as part of the research team. Three group of chronic diseases have been selected regarding the specificities of the care network they mobilize: (1) cystic fibrosis and kidney disease, (2) hemophilia, and (3) mental health disorders. Four consecutive phases will be conducted, including (1) preparatory interviews with medical or associative actors of each pathology field; (2) in-depth individual interviews with patients of each pathology, analyzed using the qualitative method of thematic analysis; (3) results of both these phases will then be triangulated through interviews with members of each patient’s care ecosystem; and finally, (4) focus groups will be organized to discuss the results with research participants (ie, representatives of chronic disease associations; patients; and actors of the medical, psychosocial, and family care network) in a research-action framework. Results The protocol study has undergone a peer review by the French National Research Agency’s scientific committee and has been approved by the research ethical committee of the University of Paris (registration number: IRB 00012020-59, June 28, 2020). The project received funding from August 2020 through April 2021. Expected results will be disseminated in 2021 and 2022. Conclusions Our findings will better inform the stakes of the current health crisis on the management of patients with chronic illness and, more broadly, any future crisis for a population deemed to be at risk. They will also improve health democracy by supporting better transferability of knowledge between the scientific and citizen communities. International Registered Report Identifier (IRRID) DERR1-10.2196/28728
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Affiliation(s)
- Élise Ricadat
- Institut La Personne en Médecine, Université de Paris, Paris, France.,Institut de la Recherche Saint Louis (IRSL), Université de Paris, Paris, France.,Centre de Recherche Psychanalyse, Médecine et Société (CRPMS), Université de Paris, Paris, France
| | - Aude Béliard
- Institut La Personne en Médecine, Université de Paris, Paris, France.,Centre de Recherche Médecine, Science, Santé, Santé mentale, Société (CERMES 3), Université de Paris, Paris, France
| | - Marie Citrini
- Représentante des Usagers Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Yann Craus
- Institut d'Histoire et de Philosophie des Sciences et des Techniques (IHPST), Université Paris 1 - Panthéon Sorbonne, Paris, France.,Institut des Humanités en Médecine (IHM), Université de Lausanne, Lausanne, Switzerland
| | - Céline Gabarro
- Institut La Personne en Médecine, Université de Paris, Paris, France.,Laboratoire Épidémiologie Clinique et Evaluation Economique appliqué aux populations Vulnérables (ECEVE), Université de Paris, Paris, France
| | - Marie-France Mamzer
- Unité de Recherche Ethics, Research, Translation (ETREs), Centre de Recherche des Cordeliers, Université de Paris, Paris, France.,Unité Fonctionnelle d'Ethique Médicale, Hôpital Necker- Enfants malades, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Ana Marques
- Etablissement Public de Santé Mentale Ville Evrard, Neuilly-sur-Marne, France
| | | | - Maria Teixeira
- Laboratoire Épidémiologie Clinique et Evaluation Economique appliqué aux populations Vulnérables (ECEVE), Université de Paris, Paris, France
| | - Marko Tocilovac
- Institut La Personne en Médecine, Université de Paris, Paris, France
| | - Livia Velpry
- Institut La Personne en Médecine, Université de Paris, Paris, France.,Centre de Recherche Médecine, Science, Santé, Santé mentale, Société (CERMES 3), Université de Paris, Paris, France.,Université Paris 8, Saint-Denis, France
| | - François Villa
- Institut La Personne en Médecine, Université de Paris, Paris, France.,Centre de Recherche Psychanalyse, Médecine et Société (CRPMS), Université de Paris, Paris, France
| | - Louise Virole
- Institut La Personne en Médecine, Université de Paris, Paris, France
| | - Céline Lefève
- Institut La Personne en Médecine, Université de Paris, Paris, France.,Laboratoire Sciences, Philosophie, Histoire (SPHERE), Université de Paris, Paris, France
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12
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Jacquier E, Laurent-Puig P, Badoual C, Burgun A, Mamzer MF. Facing new challenges to informed consent processes in the context of translational research: the case in CARPEM consortium. BMC Med Ethics 2021; 22:21. [PMID: 33653311 PMCID: PMC7927247 DOI: 10.1186/s12910-021-00592-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 02/22/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In the context of translational research, researchers have increasingly been using biological samples and data in fundamental research phases. To explore informed consent practices, we conducted a retrospective study on informed consent documents that were used for CARPEM's translational research programs. This review focused on detailing their form, their informational content, and the adequacy of these documents with the international ethical principles and participants' rights. METHODS Informed consent forms (ICFs) were collected from CARPEM investigators. A content analysis focused on information related to biological samples and data treatment (context of sampling and collect, aims, reuse, consent renewal), including the type of consent. An automatic assessment of the readability of the ICFs were performed with the IT program "Flesch Score". RESULTS 29 ICFs from 25 of 49 studies were analyzed after selection criteria were applied. Three types of consent were identified: 11 broad consents, six specific consents, and two opt-out consents. The Flesch Scores showed that most of the documents were too complex to be fully understood by most of the potential research participants. Most of the biological samples were collected during the healthcare routine, but the information content about secondary use of biological samples varied between ICFs. All documents mentioned personal data treatment but information about their reuse was not standardized in the ICFs. CONCLUSIONS Our review of current IC procedures of CARPEM showed that practices could be improved considering new translational research methods. "Old fashion written ICFs" should be adapted to the translational research approach, to better respect individual rights and international research ethics principles. In this context, theoretically, a digital tool allowing dynamic information and consent of participants, through an electronic interactive platform may be a good way to promote more active participation in research. Nevertheless, its feasibility in the complex environment of biological samples and data research remains to prove. The way of a combination of a broad consent followed by dynamic information may be alternatively tested.
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Affiliation(s)
- Elise Jacquier
- Centre de Recherche Des Cordeliers (UMRS 1138), INSERM, Sorbonne Université, Université de Paris, Team ETREs, 75006 Paris, France
| | - Pierre Laurent-Puig
- Centre de Recherche Des Cordeliers (UMRS 1138), Team Personalized Medicine, INSERM, Sorbonne Université, Université de Paris, Pharmacogenomics and Therapeutic Optimization, 75006 Paris, France
- Pharmacogénétique Et Oncologie Moléculaire, Hôpital Européen Georges Pompidou, Assistance publique – Hôpitaux de Paris, Paris, France
| | - Cécile Badoual
- Centre de Ressources Biologiques, Service d’anatomo-pathologie, Hôpital Européen Georges Pompidou, Assistance publique – Hôpitaux de Paris, Paris, France
| | - Anita Burgun
- Département D’informatique Médicale, de Biostatistique Et de Santé Publique, Hôpital Européen Georges Pompidou, Assistance publique – Hôpitaux de Paris, Paris, France
- UMR-S 1138, Centre de Recherche Des Cordeliers, Paris, France
- Faculté de Médecine, Université Paris Descartes, Sorbonne Universités, Paris, France
| | - Marie-France Mamzer
- Centre de Recherche Des Cordeliers (UMRS 1138), INSERM, Sorbonne Université, Université de Paris, Team ETREs, 75006 Paris, France
- Unité Fonctionnelle D’éthique Et Médecine Légale, Hôpital Necker-Enfants Maladies, Paris, France
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Gesbert C, Torregrosa C, Mamzer MF. [From incidentaloma to secondary discovery]. Med Sci (Paris) 2020; 36:1054-1058. [PMID: 33151867 DOI: 10.1051/medsci/2020188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The term incidentaloma, created in 1982, has spread throughout medical literature. However, there does not seem to be a precise definition to describe what an incidentaloma is. In the initial uses, the word incidentaloma systematically designated a mass that was detected during an imaging examination prescribed for diagnostic purposes unrelated to the reason for carrying out the examination. Naming this mass "incidentaloma" did not give any precision on its nature as it can be located in many anatomical zones, secreting or not, benign or malignant, etc. Today, the term "incidentaloma" carries a much broader dimension which seems to cover the notion of incidental discovery, whether radiological, biological or genetic. The evolution of the term "incidentaloma" demonstrates its heuristic nature. It is a sign of a change in modern medicine which hesitates between a patient clinic and a data clinic. Fortuitous discoveries are a phenomenon known and anticipated by radiologists. Thus, these discoveries are no longer fortuitous, or even unexpected, but secondary to the use of health technology.
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Affiliation(s)
- Cédric Gesbert
- Centre de recherche des Cordeliers, Sorbonne Université, Université de Paris, Inserm, Laboratoire ETREs, F-75006, Paris, France
| | - Cécile Torregrosa
- Centre de recherche des Cordeliers, Sorbonne Université, Université de Paris, Inserm, Laboratoire ETREs, F-75006, Paris, France
| | - Marie-France Mamzer
- Centre de recherche des Cordeliers, Sorbonne Université, Université de Paris, Inserm, Laboratoire ETREs, F-75006, Paris, France - Unité fonctionnelle d'éthique médicale, Hôpital Necker-Enfants malades, APHP, 149 rue de Sèvres, 75015 Paris, France
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14
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Mamzer MF, Dubois S, Saout C, Albin N, Béhier JM, Buisson A, Diebolt V, Delaitre O, Duguet C, Fagon JY, Gaillard S, Le Jeunne C, Mazars R, Micallef J, Nabarette H, Piazza L, Raynaud C, Varoqueaux N. Comment renforcer la place des patients dans les évaluations des technologies de santé faites par les autorités de santé. Therapie 2018; 73:83-93. [DOI: 10.1016/j.therap.2017.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 11/27/2017] [Indexed: 10/18/2022]
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15
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Morin S, Leroy P, Aubaret C, Legeay K, Saadi A, Brami C, Gervais C, Herve C, Mamzer MF, Sauvajot C, Guillou A, Garnier B, Lecuru F, Waechter L, Scotte F. Cost effectiveness in a supportive care unit. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.e18326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18326 Background: Supportive care in cancer (SCC) may create a financial burden, compared to a standard cancer department. In 2011, a specific SCC inpatient unit was developed in an academic hospital, based on a multidisciplinary approach in order to anticipate patient’s disability and limit emergency hospitalization. Assess the cost effectiveness of the SCC unit expenses and benefits compared to Medical (MO) and Gastro-Intestinal (GI) oncology departments. Methods: Data were analyzed over a six year period (2011-2016). Cost of hospital stays and cost per year were calculated based on the hospital’s standard cost accounting method. Hospital benefits were calculated as the difference between total incomes and total expenses (cost and Diagnosis Related Group tariffs for the stay) and results were compared (period available for comparison 2011 to 2014). Results: Total costs for the hospital, primarily due to staff expenses, were lower for the SCC unit compared to MO and GI in 2011 and 2014, as well as the daily cost per stay (DCS). Benefit per year was also higher for the SCC unit permitting it, to benefit financially compared to the two other oncology units (Table). Incomes reimbursed by the National Health system for SCC unit were 1,632,601 euros in 2015 and 2,096,285 euros in 2016 with a total of 357 and 408 patients admitted in the 8 bed SCC unit in 2015 and 2016 respectively. Conclusions: The SCC unit was less expensive to operate compared to our other oncology units. Our results suggest that its development permitted the oncology department to enhance its quality of care without any additional expenses. [Table: see text]
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Affiliation(s)
- Sophie Morin
- Supportive Cancer Care Unit, Georges Pompidou European Hospital Cancer Care Unit, Georges Pompidou European Hospital, Paris, France
| | - Pauline Leroy
- Supportive Care Unit, Medical Oncology Department, Georges Pompidou European Hospital, Paris, France
| | - Christophe Aubaret
- Supportive Care Unit, Medical Oncology Department, Georges Pompidou European Hospital, Paris, France
| | - Karine Legeay
- Supportive Cancer Care Unit, Georges Pompidou European Hospital, Paris, France
| | - Alexandre Saadi
- Supportive Care Unit, Georges Pompidou European Hospital, Paris, France
| | - Cloé Brami
- Supportive Care Unit, Georges Pompidou European Hospital, Paris, France
| | - Claire Gervais
- Supportive Care Unit, Georges Pompidou European Hospital, Paris, France
| | | | | | - Clarisse Sauvajot
- Supportive Care Unit, Medical Oncology Department, Georges Pompidou European Hospital, Paris, France
| | - Anne Guillou
- Supportive Care Unit, Medical Oncology Department, Georges Pompidou European Hospital, Paris, France
| | - Barbara Garnier
- Medical Oncology Department, Georges Pompidou European Hospital, Paris, France
| | - Fabrice Lecuru
- GINECO and European Georges Pompidou Hospital, Paris, France
| | - Lorraine Waechter
- Supportive Care Unit, Georges Pompidou European Hospital, Paris, France
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Mamzer MF, Duchange N, Darquy S, Marvanne P, Rambaud C, Marsico G, Cerisey C, Scotté F, Burgun A, Badoual C, Laurent-Puig P, Hervé C. Erratum to: Partnering with patients in translational oncology research: ethical approach. J Transl Med 2017; 15:80. [PMID: 28433049 PMCID: PMC5401763 DOI: 10.1186/s12967-017-1181-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Marie-France Mamzer
- Laboratoire d'Ethique Médicale et Médecine Légale EA4569, Faculté de Médecine, Université Paris Descartes, 45 rue des Saints-Pères, 75006, Paris, France. .,Unité fonctionnelle d'éthique et médecine légale, Hôpital Necker-Enfants malades, Assistance publique-Hôpitaux de Paris, 75015, Paris, France.
| | - Nathalie Duchange
- Laboratoire d'Ethique Médicale et Médecine Légale EA4569, Faculté de Médecine, Université Paris Descartes, 45 rue des Saints-Pères, 75006, Paris, France
| | - Sylviane Darquy
- Laboratoire d'Ethique Médicale et Médecine Légale EA4569, Faculté de Médecine, Université Paris Descartes, 45 rue des Saints-Pères, 75006, Paris, France
| | | | - Claude Rambaud
- Collectif Interassociatif Sur la Santé (CISS), 75007, Paris, France
| | | | | | - Florian Scotté
- Laboratoire d'Ethique Médicale et Médecine Légale EA4569, Faculté de Médecine, Université Paris Descartes, 45 rue des Saints-Pères, 75006, Paris, France.,Soins de support, Service de cancérologie, Hôpital Européen Georges Pompidou, Assistance publique-Hôpitaux de Paris, 75015, Paris, France
| | - Anita Burgun
- Département d'informatique médicale, de biostatistique et de santé publique, Hôpital Européen Georges Pompidou, Assistance publique-Hôpitaux de Paris, 75015, Paris, France.,UMR-S 1138, Centre de recherche des Cordeliers, 75006, Paris, France.,Faculté de médecine Paris Descartes, Sorbonne universités, Paris, France
| | - Cécile Badoual
- Centre de Ressources biologiques, Service d'anatomo-pathologie, Hôpital Européen Georges Pompidou, Assistance publique-Hôpitaux de Paris, 75015, Paris, France
| | - Pierre Laurent-Puig
- Inserm UMR-S 1147, Université Paris Descartes, 75006, Paris, France.,Service de Biochimie Pharmacogénétique et Oncologie Moléculaire, Hôpital Européen Georges Pompidou, Assistance publique-Hôpitaux de Paris, 75015, Paris, France
| | - Christian Hervé
- Laboratoire d'Ethique Médicale et Médecine Légale EA4569, Faculté de Médecine, Université Paris Descartes, 45 rue des Saints-Pères, 75006, Paris, France
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Lazareth H, Cohen D, Vasiliu V, Tinel C, Martinez F, Grünfeld JP, Mamzer MF, Legendre C, Sberro-Soussan R. Paraganglioma of the bladder in a kidney transplant recipient: A case report. Mol Clin Oncol 2017; 6:553-555. [PMID: 28413667 DOI: 10.3892/mco.2017.1182] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 01/30/2017] [Indexed: 12/30/2022] Open
Abstract
Renal transplantation has been associated with a significantly increased risk of developing cancer, including bladder neoplasia, with urothelial carcinoma being the most frequent type of bladder cancer. Bladder paraganglioma, also referred to as extra-adrenal pheochromocytoma, is a rare but severe condition that may cause a severe hypertensive crisis during handling and mobilization of the tumor. We herein present the case of a 67-year-old kidney transplant recipient with a bladder polyp consistent with paraganglioma of the bladder. During bladder polyp resection, the patient developed severe hypertension, which resolved with appropriate treatment. The histological analysis of the resected bladder polyp was consistent with extra-adrenal pheochromocytoma, or paraganglioma, and the patient finally underwent partial cystectomy, with no reported postoperative recurrence. To the best of our knowledge, this is the first report of a case of paraganglioma of the bladder in a kidney tranplant recipient. Total or partial bladder cystectomy is considered to be an effective treatment for this type of bladder tumor. Screening for mutations of the succinate dehydrogenase subunit B gene may also be recommended.
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Affiliation(s)
- Hélène Lazareth
- Department of Nephrology and Kidney Transplantation, Necker Enfants-Malades Hospital, Paris Descartes University, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France
| | - Daniel Cohen
- Department of Urology, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France
| | - Viorel Vasiliu
- Department of Pathology, Necker Enfants-Malades Hospital, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France
| | - Claire Tinel
- Department of Nephrology and Kidney Transplantation, Necker Enfants-Malades Hospital, Paris Descartes University, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France
| | - Frank Martinez
- Department of Nephrology and Kidney Transplantation, Necker Enfants-Malades Hospital, Paris Descartes University, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France
| | - Jean-Pierre Grünfeld
- Department of Nephrology and Kidney Transplantation, Necker Enfants-Malades Hospital, Paris Descartes University, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France
| | - Marie-France Mamzer
- Department of Medical Ethics and Legal Medicine, Paris Descartes University, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France
| | - Christophe Legendre
- Department of Nephrology and Kidney Transplantation, Necker Enfants-Malades Hospital, Paris Descartes University, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France
| | - Rebecca Sberro-Soussan
- Department of Nephrology and Kidney Transplantation, Necker Enfants-Malades Hospital, Paris Descartes University, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France
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18
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Mamzer MF, Duchange N, Darquy S, Marvanne P, Rambaud C, Marsico G, Cerisey C, Scotté F, Burgun A, Badoual C, Laurent-Puig P, Hervé C. Partnering with patients in translational oncology research: ethical approach. J Transl Med 2017; 15:74. [PMID: 28390420 PMCID: PMC5385033 DOI: 10.1186/s12967-017-1177-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 04/01/2017] [Indexed: 11/10/2022] Open
Abstract
Background The research program CARPEM (cancer research and personalized medicine) brings together the expertise of researchers and hospital-based oncologists to develop translational research in the context of personalized or “precision” medicine for cancer. There is recognition that patient involvement can help to take into account their needs and priorities in the development of this emerging practice but there is currently no consensus about how this can be achieved. In this study, we developed an empirical ethical research action aiming to improve patient representatives’ involvement in the development of the translational research program together with health professionals. The aim is to promote common understanding and sharing of knowledge between all parties and to establish a long-term partnership integrating patient’s expectations. Methods Two distinct committees were settled in CARPEM: an “Expert Committee”, gathering healthcare and research professionals, and a “Patient Committee”, gathering patients and patient representatives. A multidisciplinary team trained in medical ethics research ensured communication between the two committees as well as analysis of discussions, minutes and outputs from all stakeholders. Results The results highlight the efficiency of the transfer of knowledge between interested parties. Patient representatives and professionals were able to identify new ethical challenges and co-elaborate new procedures to gather information and consent forms for adapting to practices and recommendations developed during the process. Moreover, included patient representatives became full partners and participated in the transfer of knowledge to the public via conferences and publications. Conclusions Empirical ethical research based on a patient-centered approach could help in establishing a fair model for coordination and support actions during cancer research, striking a balance between the regulatory framework, researcher needs and patient expectations. Our approach addresses the concept of translational ethics as a way to handle the main remaining gap between combining care and research activities in the medical pathway and the existing framework.
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Affiliation(s)
- Marie-France Mamzer
- Laboratoire d'Ethique Médicale et Médecine Légale EA4569, Faculté de Médecine, Université Paris Descartes, 45 rue des Saints-Pères, 75006, Paris, France. .,Unité fonctionnelle d'éthique et médecine légale, Hôpital Necker-Enfants malades, Assistance publique-Hôpitaux de Paris, 75015, Paris, France.
| | - Nathalie Duchange
- Laboratoire d'Ethique Médicale et Médecine Légale EA4569, Faculté de Médecine, Université Paris Descartes, 45 rue des Saints-Pères, 75006, Paris, France
| | - Sylviane Darquy
- Laboratoire d'Ethique Médicale et Médecine Légale EA4569, Faculté de Médecine, Université Paris Descartes, 45 rue des Saints-Pères, 75006, Paris, France
| | | | - Claude Rambaud
- Collectif Interassociatif Sur la Santé (CISS), 75007, Paris, France
| | | | | | - Florian Scotté
- Laboratoire d'Ethique Médicale et Médecine Légale EA4569, Faculté de Médecine, Université Paris Descartes, 45 rue des Saints-Pères, 75006, Paris, France.,Soins de support, Service de cancérologie, Hôpital Européen Georges Pompidou, Assistance publique-Hôpitaux de Paris, 75015, Paris, France
| | - Anita Burgun
- Département d'informatique médicale, de biostatistique et de santé publique, Hôpital Européen Georges Pompidou, Assistance publique-Hôpitaux de Paris, 75015, Paris, France.,UMR-S 1138, Centre de recherche des Cordeliers, 75006, Paris, France.,Faculté de médecine Paris Descartes, Sorbonne universités, Paris, France
| | - Cécile Badoual
- Centre de Ressources biologiques, Service d'anatomo-pathologie, Hôpital Européen Georges Pompidou, Assistance publique-Hôpitaux de Paris, 75015, Paris, France
| | - Pierre Laurent-Puig
- Inserm UMR-S 1147, Université Paris Descartes, 75006, Paris, France.,Service de Biochimie Pharmacogénétique et Oncologie Moléculaire, Hôpital Européen Georges Pompidou, Assistance publique-Hôpitaux de Paris, 75015, Paris, France
| | - Christian Hervé
- Laboratoire d'Ethique Médicale et Médecine Légale EA4569, Faculté de Médecine, Université Paris Descartes, 45 rue des Saints-Pères, 75006, Paris, France
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Jannot AS, Zapletal E, Avillach P, Mamzer MF, Burgun A, Degoulet P. The Georges Pompidou University Hospital Clinical Data Warehouse: A 8-years follow-up experience. Int J Med Inform 2017; 102:21-28. [PMID: 28495345 DOI: 10.1016/j.ijmedinf.2017.02.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 02/11/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND When developed jointly with clinical information systems, clinical data warehouses (CDWs) facilitate the reuse of healthcare data and leverage clinical research. OBJECTIVE To describe both data access and use for clinical research, epidemiology and health service research of the "Hôpital Européen Georges Pompidou" (HEGP) CDW. METHODS The CDW has been developed since 2008 using an i2b2 platform. It was made available to health professionals and researchers in October 2010. Procedures to access data have been implemented and different access levels have been distinguished according to the nature of queries. RESULTS As of July 2016, the CDW contained the consolidated data of over 860,000 patients followed since the opening of the HEGP hospital in July 2000. These data correspond to more than 122 million clinical item values, 124 million biological item values, and 3.7 million free text reports. The ethics committee of the hospital evaluates all CDW projects that generate secondary data marts. Characteristics of the 74 research projects validated between January 2011 and December 2015 are described. CONCLUSION The use of HEGP CDWs is a key facilitator for clinical research studies. It required however important methodological and organizational support efforts from a biomedical informatics department.
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Affiliation(s)
- Anne-Sophie Jannot
- Paris Descartes Faculty of Medicine, Paris, France; INSERM UMR 1138-E22: Information Sciences to Support Personalized Medicine, Paris, France; Medical Informatics, Biostatistics and Public Health Department, Georges Pompidou University Hospital, Paris, France.
| | - Eric Zapletal
- Medical Informatics, Biostatistics and Public Health Department, Georges Pompidou University Hospital, Paris, France
| | - Paul Avillach
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Marie-France Mamzer
- Paris Descartes Faculty of Medicine, Paris, France; INSERM EA 4569 Medical Ethics Department
| | - Anita Burgun
- Paris Descartes Faculty of Medicine, Paris, France; INSERM UMR 1138-E22: Information Sciences to Support Personalized Medicine, Paris, France; Medical Informatics, Biostatistics and Public Health Department, Georges Pompidou University Hospital, Paris, France
| | - Patrice Degoulet
- Paris Descartes Faculty of Medicine, Paris, France; INSERM UMR 1138-E22: Information Sciences to Support Personalized Medicine, Paris, France; Medical Informatics, Biostatistics and Public Health Department, Georges Pompidou University Hospital, Paris, France
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20
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Morizot G, Jouffroy R, Faye A, Chabert P, Belhouari K, Calin R, Charlier C, Miailhes P, Siriez JY, Mouri O, Yera H, Gilquin J, Tubiana R, Lanternier F, Mamzer MF, Legendre C, Peyramond D, Caumes E, Lortholary O, Buffet P. Antimony to Cure Visceral Leishmaniasis Unresponsive to Liposomal Amphotericin B. PLoS Negl Trop Dis 2016; 10:e0004304. [PMID: 26735920 PMCID: PMC4703342 DOI: 10.1371/journal.pntd.0004304] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 11/24/2015] [Indexed: 02/07/2023] Open
Abstract
We report on 4 patients (1 immunocompetent, 3 immunosuppressed) in whom visceral leishmaniasis had become unresponsive to (or had relapsed after) treatment with appropriate doses of liposomal amphotericin B. Under close follow-up, full courses of pentavalent antimony were administered without life-threatening adverse events and resulted in rapid and sustained clinical and parasitological cure. Visceral leishmaniasis causes fever, enlargement of internal organs like the liver and the spleen, and leads to death if no treatment is given. It is caused by a microbe called Leishmania and affects children and adults in warm and temperate regions of the world. Antimony in different forms has been used to treat Visceral Leishmaniasis for almost one century and is still in use in several countries despite the fact that it sometimes displays toxic effects, especially in patients with underlying health problems. Because it is better tolerated and at least as effective as antimony, liposomal amphotericin B is now used as the first treatment for Visceral Leishmaniasis in Southern Europe. We observed that a small proportion of patients—especially those with an impaired immune system—do not cure even after several courses of liposomal amphotericin B. In 4 such patients with “unresponsiveness” to liposomal amphotericin B, antimony provided a sustained cure without major side effects. We conclude that when multiple failures or relapses occur after treatment with liposomal amphotericin B, antimony is a reasonable, potentially life-saving treatment option. These observations also suggest that “unresponsiveness” to amphotericin B results from unusual resistance mechanisms.
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Affiliation(s)
| | - Romain Jouffroy
- Service d’anesthésie-réanimation, Hôpital Necker, Paris, France
| | - Albert Faye
- Service de Pédiatrie générale, Hôpital Robert Debré, Paris, France
| | - Paul Chabert
- Service de Maladies Infectieuses et Tropicales, Hôpital de la Croix-Rousse, Lyon, France
| | - Katia Belhouari
- Service de Maladies Infectieuses et Tropicales, Hôpital Pitié-Salpêtrière, Université Pierre et Marie Curie, Paris, France
| | - Ruxandra Calin
- Service de Maladies Infectieuses et Tropicales, Hôpital Pitié-Salpêtrière, Université Pierre et Marie Curie, Paris, France
| | - Caroline Charlier
- Université Paris Descartes, Centre d’Infectiologie Necker-Pasteur, Hôpital Necker-Enfants malades, IHU Imagine, Paris, France
| | - Patrick Miailhes
- Service de Maladies Infectieuses et Tropicales, Hôpital de la Croix-Rousse, Lyon, France
| | - Jean-Yves Siriez
- Service d'Accueil des Urgences pédiatriques, Hôpital Robert Debré, Paris, France
| | - Oussama Mouri
- Service de Parasitologie-Mycologie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Hélène Yera
- Service de Parasitologie-Mycologie. Hôpital Cochin, Faculté de Médecine, Paris Descartes, Paris, France
| | - Jacques Gilquin
- Université Paris Descartes, Centre d’Infectiologie Necker-Pasteur, Hôpital Necker-Enfants malades, IHU Imagine, Paris, France
| | - Roland Tubiana
- Service de Maladies Infectieuses et Tropicales, Hôpital Pitié-Salpêtrière, Université Pierre et Marie Curie, Paris, France
| | - Fanny Lanternier
- Université Paris Descartes, Centre d’Infectiologie Necker-Pasteur, Hôpital Necker-Enfants malades, IHU Imagine, Paris, France
| | | | | | - Dominique Peyramond
- Service de Maladies Infectieuses et Tropicales, Hôpital de la Croix-Rousse, Lyon, France
| | - Eric Caumes
- Service de Maladies Infectieuses et Tropicales, Hôpital Pitié-Salpêtrière, Université Pierre et Marie Curie, Paris, France
| | - Olivier Lortholary
- Université Paris Descartes, Centre d’Infectiologie Necker-Pasteur, Hôpital Necker-Enfants malades, IHU Imagine, Paris, France
| | - Pierre Buffet
- Service de Parasitologie-Mycologie, Hôpital Pitié-Salpêtrière, Paris, France
- 945 INSERM, Université Paris 6, Paris, France
- * E-mail:
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Lesieur O, Leloup M, Gonzalez F, Mamzer MF. Withholding or withdrawal of treatment under French rules: a study performed in 43 intensive care units. Ann Intensive Care 2015; 5:56. [PMID: 26092498 PMCID: PMC4486647 DOI: 10.1186/s13613-015-0056-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 05/28/2015] [Indexed: 01/24/2023] Open
Abstract
Background In France, decisions to limit treatment fall under the Leonetti law adopted in 2005. Leading figures from the French world of politics, science, and justice recently claimed for amendments to the law, considering it incomplete. This study, conducted before any legislative change, aimed to investigate the procedural aspects of withholding/withdrawing treatment in French ICUs and their adequacy with the existing law. Methods The characteristics of patients qualified for a withholding/withdrawal procedure were prospectively collected in 43 French ICUs. The study period (60 or 90 days under normal operating conditions) took place in the first half of 2013. Results During the study period, 777 (14 %) of 5589 admitted patients and 584 (52 %) of 1132 patients dying in the ICU had their treatment withheld or withdrawn. Whereas 344 patients had treatment(s) withheld (i.e., not started or not increased if already engaged), 433 had one or more treatment(s) withdrawn. Withdrawal of treatment was applied in 156 of 223 (70 %) brain-injured patients, compared to 277 of 554 (50 %) patients with other reasons for admission (p < 0.01). At the time of the decision-making, the patient’s wishes were known in 181 (23 %) of the 777 cases in one or more different way(s): 73 (9.4 %) from the patient, 10 (1.3 %) by advance directives, 10 (1.3 %) through a designated trusted person, and 108 (13.9 %) reported by the family or close relatives. An external consultant was involved in less than half of all decisions (356 of 777, 46 %). Of the 777 patients qualified for a withholding/withdrawal procedure, 133 (17 %) were discharged alive from the hospital (126 after withholding, 7 after withdrawal). Conclusions More than half of deaths in the study population occurred after a decision to withhold or withdraw treatment. Among patients under withholding/withdrawal procedures, brain-injured subjects were more likely to undergo a withdrawal procedure. The prevalence of advance directives and designated trusted persons was low. Because patients’ preferences were unknown in more than three quarters of cases, decisions remained primarily based on medical judgment. Limitations, especially withholding of treatment, did not preclude survival and hospital discharge.
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Pilmis B, Scemla A, Join-Lambert O, Mamzer MF, Lortholary O, Legendre C, Zahar JR. ESBL-producing enterobacteriaceae-related urinary tract infections in kidney transplant recipients: incidence and risk factors for recurrence. Infect Dis (Lond) 2015; 47:714-8. [DOI: 10.3109/23744235.2015.1051107] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Tomczyk M, Viallard ML, Beloucif S, Mamzer MF, Hervé C. Sédation continue maintenue jusqu’au décès : comment en informer le malade et recueillir son consentement ? Médecine Palliative : Soins de Support - Accompagnement - Éthique 2015. [DOI: 10.1016/j.medpal.2015.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lesieur O, Leloup M, Gonzalez F, Mamzer MF. Eligibility for organ donation following end-of-life decisions: a study performed in 43 French intensive care units. Intensive Care Med 2014; 40:1323-31. [DOI: 10.1007/s00134-014-3409-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 07/15/2014] [Indexed: 01/15/2023]
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Bommier C, Mamzer MF, Desmarchelier D, Hervé C. How nonverbal communication shapes the doctor-patient relationship: from paternalism to the ethics of care in oncology. ACTA ACUST UNITED AC 2014; 24:137-58, 185. [PMID: 24558741 DOI: 10.3917/jib.243.0135] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The purpose of this research, led in the wake of years of pressure to reject paternalism, was to study whether controlled practice of nonverbal communication by doctors inheres a continued risk of paternalistic attitudes in oncology clinic interviews (chosen to illustrate the doctor-patient relationship). This study involved qualitative descriptive research based on interview observations and questionnaires and mobilized recognized theory borrowed from sociology and anthropology. We found that the legislative framework governing the doctor-patient relationship has simply shifted the paternalism issue from verbal communication over to a new area that doctors have not yet mastered and patients have not yet understood, i.e., nonverbal communication. This study shows that all the laws framing the doctor-patient relationship can be circumvented, and that by controlling nonverbal communication, the doctor can fall back into paternalism. The rejection of paternalism therefore needs to lead to an appropriate reading of the patient's story, which in ethical terms can only happen if hospital structures are made non-paternalizing by design, if doctors learn to understand the patient's different chronemic timeframe, and if doctors committedly engage in the Hippocratic Oath codified through the ethics of care.
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Affiliation(s)
| | | | | | - C Hervé
- Laboratoire d'Ethique Médicale et de Médecine, Légale, Université Paris Descartes, PRES Sorbonne Paris Cité, France
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Mallet V, Le Mener S, Roque-Afonso AM, Tsatsaris V, Mamzer MF. Chronic hepatitis E infection cured by pregnancy. J Clin Virol 2013; 58:745-7. [PMID: 24140032 DOI: 10.1016/j.jcv.2013.09.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 09/20/2013] [Accepted: 09/24/2013] [Indexed: 11/16/2022]
Affiliation(s)
- Vincent Mallet
- Institut Cochin, Université Paris Descartes (Unité Mixte de Recherche S1016), Centre National de la Recherche Scientifique (Unité Mixte de Recherche 8104), Institut National de la Santé et de la Recherche Médicale U.1016, Assistance Publique-Hôpitaux de Paris, France.
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Bertrand D, Pallet N, Sartorius A, Zahar JR, Soussan RS, Lortholary O, Legendre C, Mamzer MF. Clinical and microbial impact of screening kidney allograft preservative solution for bacterial contamination with high-sensitivity methods. Transpl Int 2013; 26:795-9. [PMID: 23734610 DOI: 10.1111/tri.12130] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 04/20/2013] [Accepted: 05/15/2013] [Indexed: 11/27/2022]
Abstract
The clinical and bacteriological consequences of routinely performing highly sensitive bacterial screening of kidney transplant preservation solution (PS) are not known. To evaluate the clinical and microbiological impacts of this strategy, we retrospectively analyzed 200 consecutive kidney allograft recipients from March 2009 to February 2011 for whom PS samples were routinely screened. PS were inoculated into aerobic and anaerobic blood culture bottles, as well as blood agar plates. A rectal swab for extended-spectrum β-lactamase-producing Enterobacteriaceae (EBSL-PE) faecal carriage was also routinely obtained from each patient at admission and every 7 days until hospital discharge. In addition, a standard culture of drain fluid was collected on the day after kidney transplantation. Complete samples and cultures of PS were performed in 165 cases (82.5%), and 62 (37.6%) had positive blood culture results. The most frequent microbial agent isolated was coagulase-negative staphylococci (51.8%). Of these 62 positive samples, only seven (11.3%) were confirmed to contain the same organism by the standard culture method. Drain fluid and PS culture positivity with the same microorganism occurred in only two patients. Of the 62 patients with positive PS cultures, 26 (41.9%) received pre-emptive antibiotic therapy initiated within 48 h post-transplant. During the hospitalization period, patients with a positive PS culture, regardless of whether they received pre-emptive antibiotic therapy, did not exhibit any invasive infections (urinary, blood, peritoneal or wound) related to the microorganisms isolated in the PS. Patients with positive PS cultures who were treated with antibiotic therapy acquired significantly more colonizing ESBL-PE than patients who did not receive antibiotics (53.8% vs. 16.6%; P = 0.01); these patients also developed more clinical infections related to the ESBL-PE (23.1% vs. 5.2%; P < 0.01). The use of antibiotics for patients with positive PS cultures was an independent risk factor for ESBL-PE acquisition in both univariate and multivariate analyses. In conclusion, the use of more sensitive culture methods increases the rate of bacterial contamination of PS and is associated with an increased prescription of antibiotics and increased ESBL-PE carriage and related infections. Therefore, the systematic use of PS blood bottle cultures in kidney transplantation may have no benefit and might increase the rate of ESBL-PE emergence.
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Affiliation(s)
- Dominique Bertrand
- Service de Transplantation Rénale et Soins Intensifs, Hôpital Necker et Université Paris Descartes, Paris, France
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Affiliation(s)
- P Charlier
- Department of Forensic Medicine, University Hospital R. Poincaré (AP-HP, UVSQ), Garches, 92380 Garches, France ; Laboratory of Medical Ethics and Forensic Medicine, University of Paris 5, 75006 Paris, France
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Bertrand D, Desbuissons G, Pallet N, Debure A, Sartorius A, Anglicheau D, Mamzer MF, Legendre C, Sberro-Soussan R. Sirolimus therapy may cause cardiac tamponade. Transpl Int 2012. [DOI: 10.1111/tri.12025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Dominique Bertrand
- Service de Transplantation Rénale et Soins Intensifs; Hôpital Necker; Assistance Publique Hôpitaux de Paris; Université Paris Descartes; Paris; France
| | - Geoffroy Desbuissons
- Service de Transplantation Rénale et Soins Intensifs; Hôpital Necker; Assistance Publique Hôpitaux de Paris; Université Paris Descartes; Paris; France
| | - Nicolas Pallet
- Service de Transplantation Rénale et Soins Intensifs; Hôpital Necker; Assistance Publique Hôpitaux de Paris; Université Paris Descartes; Paris; France
| | - Alain Debure
- Service de Transplantation Rénale et Soins Intensifs; Hôpital Necker; Assistance Publique Hôpitaux de Paris; Université Paris Descartes; Paris; France
| | - Albane Sartorius
- Service de Transplantation Rénale et Soins Intensifs; Hôpital Necker; Assistance Publique Hôpitaux de Paris; Université Paris Descartes; Paris; France
| | - Dany Anglicheau
- Service de Transplantation Rénale et Soins Intensifs; Hôpital Necker; Assistance Publique Hôpitaux de Paris; Université Paris Descartes; Paris; France
| | - Marie-France Mamzer
- Service de Transplantation Rénale et Soins Intensifs; Hôpital Necker; Assistance Publique Hôpitaux de Paris; Université Paris Descartes; Paris; France
| | - Christophe Legendre
- Service de Transplantation Rénale et Soins Intensifs; Hôpital Necker; Assistance Publique Hôpitaux de Paris; Université Paris Descartes; Paris; France
| | - Rebecca Sberro-Soussan
- Service de Transplantation Rénale et Soins Intensifs; Hôpital Necker; Assistance Publique Hôpitaux de Paris; Université Paris Descartes; Paris; France
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Courbebaisse M, Diet C, Timsit MO, Mamzer MF, Thervet E, Noel LH, Legendre C, Friedlander G, Martinez F, Prié D. Effects of cinacalcet in renal transplant patients with hyperparathyroidism. Am J Nephrol 2012; 35:341-8. [PMID: 22473131 DOI: 10.1159/000337526] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 02/28/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cinacalcet decreases serum parathyroid hormone (PTH) and calcium concentrations in kidney transplant recipients with autonomous hyperparathyroidism. Long-term treatment with cinacalcet may increase urinary calcium excretion and the risk of renal calcium deposits and may alter renal graft function. METHODS We studied 71 renal recipients with hypercalcemic hyperparathyroidism. Of these patients, 34 received cinacalcet between month 3 and month 12 after renal transplantation. We compared phosphate calcium balance, measured glomerular filtration rate (GFR) and renal biopsies in cinacalcet-treated and non-cinacalcet-treated patients. Measurements were performed before initiating cinacalcet treatment (month 3) and at month 12. RESULTS Patients treated with cinacalcet had more severe hyperparathyroidism. Serum PTH concentration decreased in both groups between months 3 and 12, but the decrease was much more important in cinacalcet-treated patients. Urinary calcium excretion significantly increased under cinacalcet treatment and was more than twice as high at month 12 as in patients who did not receive cinacalcet treatment. However, the hypercalciuria was not associated with an increase in calcium deposits on renal biopsies or an alteration of measured GFR. CONCLUSIONS Despite sustained and marked hypercalciuria induced by cinacalcet treatment, cinacalcet does not have adverse effects on GFR or on renal graft calcium deposits in the first year following renal transplantation.
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Affiliation(s)
- Marie Courbebaisse
- Service d'Explorations Fonctionnelles, Hôpital Necker-Enfants malades Assistance Publique-Hôpitaux de Paris, Paris, France
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Thervet E, Aouizerate J, Noel LH, Brocheriou I, Martinez F, Mamzer MF, Legendre C. Histologic recurrence of Henoch-Schonlein Purpura nephropathy after renal transplantation on routine allograft biopsy. Transplantation 2011; 92:907-12. [PMID: 21869738 DOI: 10.1097/tp.0b013e31822e0bcf] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Henoch-Schonlein Purpura nephropathy (HSPN) recurrence in renal transplant recipients (RTRs) has been reported in 35% of patients, leading in 11% of these patients to graft loss at 5 years. However, its true incidence is unknown. The aim of this study was to investigate this recurrence incidence using routine allograft biopsies (RBs). METHODS All RTRs with biopsy-proven HSP initial nephropathy were included (13 RTRs and 18 renal transplantations). At transplantation, the median age was 34 years, and 85% of RTRs were men. Overall, we analyzed 66 RBs that were routinely performed at 3 and 12 months after RT and when clinically indicated. Histologic recurrence was defined as the presence of IgA deposits within the mesangium and along the glomerular capillary walls. RESULTS After a median follow-up of 83 months (range, 13-232 months; interquartile range, 26-235 months), histologic recurrence was detected in 69% of patients and in 61% of grafts after a mean period of 24 months (range, 1-156 months). Clinical or biological signs were absent in all but one. Patient survival was 92.8%. Graft loss occurred in five cases, never were related to recurrence. At the last follow-up, the mean glomerular filtration rate was 48±14.2 mL/min/1.73 m(2); in patients with and without recurrence, the mean rates were 52.1±17.5 and 42.4±5.3 mL/min/1.73 m(2), respectively (P=0.27). CONCLUSION Histologic recurrence of HSPN after RT is frequently observed on routine RBs but is not associated with clinical consequences. The short-term prognosis of recurrence is good, but its long-term prognosis remains to be determined.
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Rammaert B, Couderc LJ, Rivaud E, Honderlick P, Zucman D, Mamzer MF, Cahen P, Bille E, Lecuit M, Lortholary O, Catherinot E. Mycobacterium genavense as a cause of subacute pneumonia in patients with severe cellular immunodeficiency. BMC Infect Dis 2011; 11:311. [PMID: 22054169 PMCID: PMC3232426 DOI: 10.1186/1471-2334-11-311] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Accepted: 11/05/2011] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Mycobacterium genavense is a rare nontuberculous mycobacteria (NTM). Human infections are mostly disseminated in the setting of the AIDS epidemic or the use of aggressive immunosuppressive treatments. M. genavense culture is fastidious, requiring supplemented media. Pulmonary involvement rarely occurs as a primary localization. CASES PRESENTATION We report here two patients with pneumonia as the predominant manifestation of M. genavense infection: one kidney transplanted patient and one HIV-infected patient. Both patients were initially treated with anti-tuberculous drugs before the identification of M. genavense on sputum or broncho-alveolar lavage fluid culture. A four-drug regimen including clarithromycin and rifabutin was started. Gamma interferon has been helpful in addition to antimycobacterial treatment for one patient. CONCLUSION Clinicians should be aware that M. genavense could be the etiologic agent of sub-acute pneumonia mimicking tuberculosis in patients with cellular immunodeficiency status.
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Affiliation(s)
- Blandine Rammaert
- Université Paris-Descartes, Hôpital Necker-Enfants Malades, Service des Maladies Infectieuses et Tropicales, Centre d'Infectiologie Necker-Pasteur, Paris, France
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Canaud G, Martinez F, Noël LH, Mamzer MF, Niaudet P, Legendre C. Therapeutic approach to focal and segmental glomerulosclerosis recurrence in kidney transplant recipients. Transplant Rev (Orlando) 2010; 24:121-8. [DOI: 10.1016/j.trre.2010.04.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Accepted: 04/18/2010] [Indexed: 10/19/2022]
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Legendre C, Kreis H, Martinez F, Snanoudj R, Mamzer MF, Sberro R, Bererhi L, Anglicheau D, Zuber J, Loupy A, Thervet E, Pallet N, Sartorius A, Bertrand D, Canaud G, Noël LH, Rabant M, Timsit MO, Méjean A. Kidney transplantation at Necker Hospital: the most recent 5-year period (2004-2009). Clin Transpl 2010:127-132. [PMID: 21696035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The results of our last 5 years activity in kidney transplantation clearly show that it is possible to perform high-risk transplantations with very acceptable results: ECD kidneys, dual transplantation, recipients with DSAs. In depth statistical analysis of these data should allow a clearer definition of the best strategies to use in these situations.
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Pallet N, Rouach Y, Correas JM, Zahar JR, Legendre C, Mamzer MF. Bilateral urinary leak originating from the native ureters in a dual kidney transplant patient. Transpl Int 2009; 23:e51-2. [PMID: 20028491 DOI: 10.1111/j.1432-2277.2009.01034.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Zafrani L, Truffaut L, Kreis H, Etienne D, Rafat C, Lechaton S, Anglicheau D, Zuber J, Ciroldi M, Thervet E, Snanoudj R, Mamzer MF, Martinez F, Timsit MO, Bergougnoux L, Legendre C. Incidence, risk factors and clinical consequences of neutropenia following kidney transplantation: a retrospective study. Am J Transplant 2009; 9:1816-25. [PMID: 19538494 DOI: 10.1111/j.1600-6143.2009.02699.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Neutropenic episodes in kidney transplant patients are poorly characterized. In this retrospective study, neutropenia was experienced by 112/395 patients (28%) during the first year posttransplant. The only factor found to be significantly associated with the occurrence of neutropenia was combined tacrolimus-mycophenolate therapy (p < 0.001). Neutropenic patients experienced more bacterial infections (43% vs. 32%, p = 0.04). Grade of neutropenia correlated with the global risk of infection. Discontinuation of mycophenolic acid (MPA) due to neutropenia was associated with an increased incidence of acute rejection (odds ratios per day 1.11, 95% confidence intervals 1.02-1.22) but not with reduced renal function at 1 year. The time from onset of neutropenia to MPA discontinuation correlated with the duration of neutropenia. Granulocyte colony-stimulating factor (G-CSF) administration was safe and effective in severely neutropenic kidney graft recipients, with absolute neutrophil count >1000/microL achieved in a mean of 1.5+/-0.5 days. Neutropenia is an important and frequent laboratory finding that may exert a significant influence on outcomes in kidney transplantation. As well as leading to an increased incidence of infection, it is associated with a higher rate of allograft rejection if MPA is discontinued for >6 days (p = 0.02). G-CSF accelerates recovery of neutropenia and may be a good therapeutic alternative for severely neutropenic patients.
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Affiliation(s)
- L Zafrani
- Service de transplantation et unité de soins intensifs, Hôpital Necker, Paris, France.
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Parize P, Chandesris MO, Lanternier F, Poirée S, Viard JP, Bienvenu B, Mimoun M, Méchai F, Mamzer MF, Herman P, Bougnoux ME, Lecuit M, Lortholary O. Antifungal therapy of Aspergillus invasive otitis externa: efficacy of voriconazole and review. Antimicrob Agents Chemother 2009; 53:1048-53. [PMID: 19104029 PMCID: PMC2650565 DOI: 10.1128/aac.01220-08] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Revised: 10/11/2008] [Accepted: 11/20/2008] [Indexed: 11/20/2022] Open
Abstract
Invasive otitis externa (IOE) due to Aspergillus is a rare, potentially life-threatening, invasive fungal infection affecting immunocompromised patients. The invasive process may lead to skull base osteomyelitis with progressive cranial nerve palsies and can result in irreversible hearing and neurological impairment. We report two cases of Aspergillus IOE treated with voriconazole alone and a literature review of antifungal therapy of Aspergillus IOE. Twenty-five patients, including the two described in the present report, were analyzed. Eighteen patients were treated with amphotericin B, and nine of them received itraconazole as an additional agent. Three patients received initial therapy with itraconazole, and one patient was treated with both voriconazole and caspofungin therapy. The two patients in the present report received voriconazole therapy alone with good clinical and biological tolerance despite prolonged treatment. The last patient did not receive antifungal therapy, as the diagnosis was made postmortem. Eighteen patients underwent an initial extensive surgical debridement. The majority of the patients had a favorable outcome, 17 patients experienced a complete recovery, and 6 showed a partial improvement. Both of the patients reported on here had favorable outcomes, and no aggressive surgical debridement was required. Although voriconazole has been shown to be effective for the treatment of invasive aspergillosis, its precise role in the management of Aspergillus IOE had not been documented. These observations demonstrate that voriconazole could be an effective and well-tolerated therapeutic option for the management of Aspergillus IOE.
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Affiliation(s)
- Perrine Parize
- Université Paris Descartes, Hôpital Necker-Enfants Malades, Paris, France
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Pallet N, Anglicheau D, Martinez F, Mamzer MF, Legendre C, Thervet E. Comparison of sequential protocol using basiliximab versus antithymocyte globulin with high-dose mycophenolate mofetil in recipients of a kidney graft from an expanded-criteria donor. Transplantation 2006; 81:949-52. [PMID: 16570022 DOI: 10.1097/01.tp.0000198417.91135.1f] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
This retrospective pilot study investigated use of high-dose mycophenolate mofetil with biological induction and sequential introduction of low-dose cyclosporine in recipients of expanded criteria donor (ECD) kidneys. Fifty-four patients received mycophenolate mofetil 3 g/day for 45 days, cyclosporine 4 mg/kg/day, prednisolone, and rabbit antithymocyte globulin (rATG, n=14) or basiliximab (n=40). Acute rejection incidence was 11.3% (7.1% with rATG, 12.6% with basiliximab). Delayed graft function was observed in 31 patients (54%). At one year, measured glomerular filtration rate was 54+/-4 ml/min, with no significant differences between induction therapies. Thirty patients (55%) required > or =1 MMF dose reduction within month 1 due to adverse events (gastrointestinal symptoms, 67%; leucopenia 33%). Leucopenia was more frequent with rATG, while gastrointestinal symptoms were more frequent with basiliximab. Cytomegalovirus replication occurred in three patients (23%) with rATG and 3 (8%) with basiliximab. In conclusion, high-dose MMF, corticosteroids, delayed low-dose cyclosporine and induction therapy offers an excellent risk-to-benefit ratio in patients receiving an ECD allograft.
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Affiliation(s)
- Nicolas Pallet
- Service de Transplantation Rénale, Hôpital Necker, 149 Rue de Sèvres, 75743 Paris Cedex 15, France
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Bassilios N, Menoyo V, Berger A, Mamzer MF, Daniel F, Cluzel P, Buisson C, Martinez F. Mesenteric ischaemia in haemodialysis patients: a case/control study. Nephrol Dial Transplant 2003; 18:911-7. [PMID: 12686664 DOI: 10.1093/ndt/gfg004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Mesenteric ischaemia is not uncommon in dialysis patients and seems to have been increasing in the last decade. However, the risk factors for mesenteric ischaemia are unclear and prognosis of patients after this type of ischaemic accident is not well defined. METHODS From January 1988 to June 1999, 15 haemodialysis patients (0.3% per patient-year) from a single institution presented with mesenteric ischaemia and the clinical, biological and radiological aspects of the ischaemia were described. To identify risk factors for mesenteric ischaemia, each ischaemic patient (case) was matched with two other haemodialysis patients not having ischaemia (controls). Survival curves were then established for the two groups. RESULTS A marked hypotensive episode was present in seven out of 15 case patients (47%) during dialysis sessions that preceded mesenteric ischaemia. Abdominal pain, guarding, fever and hyperleucocytosis were all present in 13 out of 15 patients (87%). An abdominal computerized tomography scan with opaque enema enabled a rapid diagnosis for six patients. The caecum was the most frequently (47%) affected segment. Twelve patients were surgically treated and the remaining three were given medical support. The two groups (case and control) were not different in cardiovascular risk factors, comorbidity, administered drugs or main haemodialysis characteristics. The median survival of the case group was 600 days, whereas 80% of the control group survived beyond this period (P=0.0132). Eleven case patients survived >3 months after mesenteric ischaemia and had a median survival of 1500 days, which was identical to their matched control patients. CONCLUSIONS Mesenteric ischaemia should be systematically suspected in patients experiencing abdominal pain during or after dialysis sessions. Prompt diagnosis and treatment usually allow for a favourable prognosis.
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Affiliation(s)
- Nader Bassilios
- CHPVR, AURA, Réseau Nephropar, Hopital Necker, 149 rue de Sèvres, F-75743 Paris Cedex 15, France.
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Timsit JF, Bruneel F, Cheval C, Mamzer MF, Garrouste-Orgeas M, Wolff M, Misset B, Chevret S, Regnier B, Carlet J. Use of tunneled femoral catheters to prevent catheter-related infection. A randomized, controlled trial. Ann Intern Med 1999; 130:729-35. [PMID: 10357691 DOI: 10.7326/0003-4819-130-9-199905040-00004] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The risk for catheter-related infection seems higher with femoral catheters than with catheters inserted at other sites. OBJECTIVE To evaluate the effect of catheter tunneling on femoral catheter-related infection in critically ill patients. DESIGN Randomized, controlled trial. SETTING Three intensive care units at academic hospitals in Paris, France. PATIENTS 345 adult patients requiring a femoral venous catheter for more than 48 hours. INTERVENTION Tunneled or nontunneled femoral catheters. MEASUREMENTS Time to occurrence of systemic catheter-related sepsis, catheter-related bloodstream infection, and quantitative catheter tip culture with a cutoff of 10(3) colony-forming units/mL. RESULTS Of 345 randomly assigned patients, 336 were evaluable. Probable systemic catheter-related sepsis occurred in 15 of 168 patients who received a nontunneled femoral catheter (controls) and in 5 of 168 patients who received a tunneled femoral catheter (estimated absolute risk reduction, 6% [95% CI, 0.9% to 11%]). Time to occurrence of catheter-related bloodstream infection was not significantly modified (relative risk, 0.28 [CI, 0.03 to 1.92]; P = 0.18); 3 events occurred in the control group and 1 event occurred in the tunneled-catheter group. After stratification by treatment center and adjustment for variables that were prognostic (use of broad-spectrum antimicrobial agents at catheter insertion) or imbalanced between both groups (mechanical ventilation at insertion), tunnelized catheterization reduced the proportion of patients who developed systemic catheter-related sepsis (relative risk, 0.25 [CI, 0.09 to 0.72]; P = 0.005) and positive quantitative culture of the catheter tip (relative risk, 0.48 [CI, 0.23 to 0.99]; P = 0.045). CONCLUSION The incidence of femoral catheter-related infections in critically ill patients can be reduced by using subcutaneous tunneling.
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Affiliation(s)
- J F Timsit
- Réanimation Polyvalente, Hôpital Saint Joseph, Paris, France
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Correas JM, Menassa L, Hélénon O, Méjean A, Boyer JC, Mamzer MF, Moreau JF. Diagnostic improvement of renal ultrasonography in humans after i.v. injection of perflenapent emulsion. Acad Radiol 1998; 5 Suppl 1:S185-8; discussion S199. [PMID: 9561077 DOI: 10.1016/s1076-6332(98)80101-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- J M Correas
- Department of Radiology, Necker Hospital, Paris, France
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Abstract
Fibrosing cholestatic hepatitis is a well-described syndrome in patients with immunodeficiency and chronic hepatitis B. It is clinically, biologically, and histologically characterized by rapidly progressive hepatic failure, a mildly elevated serum aminotransferase level, an extensive periportal fibrosis associated with intense cholestasis, mild inflammatory cellular infiltrate, no cirrhosis, and a high hepatocellular level expression of B viral antigens. This syndrome reflected a direct hepatocytopathic injury linked to high intrahepatic viral antigen expression. Because the syndrome of fibrosing cholestatic hepatitis has not been described in chronic hepatitis C, we report the first well-characterized case in a renal transplant patient with chronic hepatitis C and discuss the clinical and pathogenic implications of such a syndrome in this setting.
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Affiliation(s)
- H Zylberberg
- Unité d'Hépatologie et Service de Transplantation Rénale, Hôpital Necker, Paris, France
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Page B, Morin MP, Mamzer MF, Thervet E, Legendre C. Use of granulocyte-macrophage colony-stimulating factor in leukopenic renal transplant recipients. Transplant Proc 1994; 26:283. [PMID: 8108982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- B Page
- Department of Transplantation, Necker Hospital, Paris, France
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Moreau R, Hadengue A, Soupison T, Mamzer MF, Kirstetter P, Saraux JL, Assous M, Roche-Sicot J, Sicot C. Arterial and mixed venous acid-base status in patients with cirrhosis. Influence of liver failure. Liver 1993; 13:20-4. [PMID: 8455422 DOI: 10.1111/j.1600-0676.1993.tb00600.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Although it has been established that liver failure is associated with arterial hypocapnia and alkalaemia (i.e., respiratory alkalosis), the influence of liver failure on mixed venous acid-base status has not yet been studied. Thus, arterial and mixed venous acid-base status were simultaneously measured in controls and in a large series of patients with cirrhosis. Grade B patients (n = 28) or Grade C patients (n = 21) had significantly lower arterial and mixed venous carbon dioxide tensions than controls (n = 29). Grade B or Grade C patients also had significantly higher arterial, mixed venous pH, and lower mixed venous bicarbonate concentrations than controls. Among Grade A patients (n = 27), those with the lowest Pugh's score (i.e., equal to five) had significantly lower mixed venous carbon dioxide tension than controls. The other arterial and mixed venous acid-base values did not differ significantly between Grade A patients with the lowest Pugh's score and controls. Grade A patients with a Pugh's score equal to six and Grade B patients had similar acid-base disorders. No significant differences were found between groups concerning the anion gap and plasma chloride concentrations. In conclusion, this study shows that in Grade B or C patients, respiratory alkalosis was responsible for mixed venous hypocapnia, alkalaemia and hypobicarbonataemia. In addition, in Grade A patients with the lowest Pugh's score (equal to five), analysis of arterial and mixed venous blood revealed that mixed venous hypocapnia was the sole anomaly of the acid-base status. This last finding suggests that mixed venous hypocapnia might be an early event preceding the onset of arterial hypocapnia.
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Affiliation(s)
- R Moreau
- Service de Réanimation et de Médecine d'Urgence, Hôpital Emile-Roux, Eaubonne, France
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Moreau R, Hadengue A, Soupison T, Kirstetter P, Mamzer MF, Vanjak D, Vauquelin P, Assous M, Sicot C. Septic shock in patients with cirrhosis: hemodynamic and metabolic characteristics and intensive care unit outcome. Crit Care Med 1992; 20:746-50. [PMID: 1597026 DOI: 10.1097/00003246-199206000-00008] [Citation(s) in RCA: 103] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To examine the hemodynamic and metabolic characteristics and ICU outcome of septic shock in patients with cirrhosis. DESIGN Prospective, comparative study. Measurements performed in the first 24 hrs of septic shock. SETTING A general hospital ICU. PATIENTS Twelve patients with cirrhosis and 23 patients without cirrhosis admitted for septic shock. MEASUREMENTS AND MAIN RESULTS Arterial pressure was measured using an arterial catheter. Pulmonary arterial and right atrial pressures were measured by using a pulmonary artery catheter. Cardiac output was determined by using the thermodilution method. Pulmonary arterial L-lactate plasma concentrations were measured using an automated spectrophotometer, and blood temperature was measured using a cardiac output computer. Arterial and mixed venous PO2, PCO2, and pH values were measured by using specific electrodes. Oxygen saturations and hemoglobin concentrations were measured using a hemoximeter. Patients with cirrhosis had decompensated liver disease (grade C of the Child-Pugh classification). The number of Gram-negative infections and therapeutic interventions were similar in both groups. Patients with cirrhosis had higher cardiac indices (5.14 +/- 0.52 [SE] vs. 3.91 +/- 0.30 L/min/m2, p less than .05), plasma lactate concentrations (9.0 +/- 2.0 vs. 5.2 +/- 0.7 mmol/L, p less than .05) and ICU mortality rates (100% vs. 43%, p less than .05), and lower blood temperatures (35.5 +/- 0.6 vs. 37.6 +/- 0.2 degrees C, p less than .05) than patients without cirrhosis. Systemic vascular resistance, arterial pressure, pulmonary arterial pressure, oxygen delivery and consumption, and arterial and mixed venous acid-base status were not significantly different between the two groups. CONCLUSIONS In patients with cirrhosis, septic shock was characterized by severe liver dysfunction, low blood temperature, marked increases in cardiac index and lactic acidemia, and a 100% ICU mortality rate. These findings should be taken into account if patients with cirrhosis are to be included in controlled studies on septic shock.
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Affiliation(s)
- R Moreau
- Service de Réanimation et de Médecine d'Urgence, Centre Hospitalier Emile-Roux, Eaubonne, France
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