Prehospital triage of acute aortic syndrome using a machine learning algorithm.

BACKGROUND: Acute aortic syndrome (AAS) comprises a complex and potentially fatal group of conditions requiring emergency specialist management. The aim of this study was to build a prediction algorithm to assist prehospital triage of AAS. METHODS: Details of consecutive patients enrolled in a regional specialist aortic network were collected prospectively. Two prediction algorithms for AAS based on logistic regression and an ensemble machine learning method called SuperLearner (SL) were developed. Undertriage was defined as the proportion of patients with AAS not transported to the specialist aortic centre, and overtriage as the proportion of patients with alternative diagnoses but transported to the specialist aortic centre. RESULTS: Data for 976 hospital admissions between February 2010 and June 2017 were included; 609 (62·4 per cent) had AAS. Overtriage and undertriage rates were 52·3 and 16·1 per cent respectively. The population was divided into a training cohort (743 patients) and a validation cohort (233). The area under the receiver operating characteristic (ROC) curve values for the logistic regression score and the SL were 0·68 (95 per cent c.i. 0·64 to 0·72) and 0·87 (0·84 to 0·89) respectively (P < 0·001) in the training cohort, and 0·67 (0·60 to 0·74) and 0·73 (0·66 to 0·79) in the validation cohort (P = 0·038). The logistic regression score was associated with undertriage and overtriage rates of 33·7 (bootstrapped 95 per cent c.i. 29·3 to 38·3) and 7·2 (4·8 to 9·8) per cent respectively, whereas the SL yielded undertriage and overtriage rates of 1·0 (0·3 to 2·0) and 30·2 (25·8 to 34·8) per cent respectively. CONCLUSION: A machine learning prediction model performed well in discriminating AAS and could be clinically useful in prehospital triage of patients with suspected AAS.

ANTECEDENTES: Los síndromes aórticos agudos (aortic acute syndromes, AAS) constituyen un grupo complejo y potencialmente letal de entidades que requieren un tratamiento especializado en emergencias. El objetivo de este estudio fue construir un algoritmo de predicción para ayudar a la selección prehospitalaria de los AAS. MÉTODOS: Se recogieron prospectivamente una serie de pacientes consecutivos inscritos en una red regional especializada en patología aórtica. Se desarrollaron dos algoritmos de predicción para AAS basados en una regresión logística y en un método de aprendizaje automático denominado Super Learner (SL). Undertriage (infra-selección) se definió como la proporción de pacientes con AAS no transportados al centro especializado en patología aórtica y el overtriage (sobre-selección) como la proporción de pacientes con diagnósticos alternativos al AAS pero transportados al centro especializado en patología aórtica. RESULTADOS: Se incluyeron los datos de 976 ingresos hospitalarios entre febrero de 2010 y junio de 2017, con 609 (62,4%) AAS. Las tasas de overtriage y undertriage fueron del 52,3% y del 16,1%, respectivamente. La población se dividió en una cohorte de entrenamiento (n = 743) y en una cohorte de validación (n = 233). El área bajo la curva ROC para la puntuación de regresión logística y el SL fueron de 0,68 (0,64, 0,72) y de 0,87 (0,84, 0,89), respectivamente (P < 0,001) en la cohorte de entrenamiento, y de 0,67 (0,60, 0,74) y de 0,73 (0,66, 0,79) en la cohorte de validación (P = 0,038). La puntuación de regresión logística se asoció con tasas de undertriage y overtriage de 33,7% (i.c. del 95% bootstrapped 29,3%, 38,3%) y de 7,2% (4,8%, 9,8%), respectivamente, mientras que el SL presentó tasas de undertriage y overtriage de 1,0% (0,3%, 2,0%) y de 30,2% (25,8%, 34,8%), respectivamente. CONCLUSIÓN: El modelo de predicción de aprendizaje automático funcionó bien para discriminar AAS y podría ser clínicamente útil en la selección prehospitalaria de pacientes con sospecha de síndrome aórtico agudo.

[Pediatric lung transplantation in Broussais-HEGP: a 23-year experience (1990-2013)]. / Transplantation pulmonaire pédiatrique : expérience de l'équipe Broussais-HEGP de 1990 à 2013.

INTRODUCTION: Pediatric lung transplantations (LTx) remains a small part of LTx performed worldwide. The majority of these Tx concerns young adolescents, transplantations in infants being anecdotic. We conducted a retrospective study of LTx in children and adolescents in one center in Paris from the beginning of the 90's to 2013. METHODS: Data from Broussais then HEGP were collected retrospectively from 1990 to 2013: 380 LTx were reported in 368 patients including 111 LTx performed among children from 5 to 18 years of age (30%). RESULTS: One hundred and eleven patients received 121 LTx: 86 bilateral LTx, 13 combined lung-liver, 3 monopulmonary, 5 heart-lung and 4 combined heart-lung-liver Tx. Eighty-eight percent of the patients had cystic fibrosis. Median age was 14 years, weight 34 kg and height 144 cm. Median age of donors was 27 years, weight 60 kg and height 167 cm. Conditional survival for children was not different than adults: 72% at one year, 42% at 5 years, 37% at 10 years and 26% at 15 years. There was not overall early mortality after transplantation. Era graft survival was significantly higher after year 2000 (53% at 5 years vs 32% P=0.03). CONCLUSION: Lung transplantation among children under 18 years have similar outcome to those of adult patients.

[Lung cancer with heart failure--a cardiac and thoracic surgeon's collaboration]. / Prise en charge chirurgicale cardiothoracique d'un cancer bronchique responsable d'une insuffisance cardiaque.

Surgical resection is a validated therapeutic option for selected cases of pulmonary tumors invading the important mediastinal structures (caval vein, atrium, aorta or supra-aortic trunks). Here, we present a patient with a necrosed pulmonary tumor invading the left atrium, causing cardiac insufficiency. A complete surgical resection under extracorporeal circulation was performed by the thoracic and cardiac teams. Admitted in a bed-ridden state, the patient was discharged completely rehabilitated on postoperative day 13. He survived 1 year at home with a good quality of life.

Mediastinitis due to Gram-negative bacteria is associated with increased mortality.

The aim of this study was to describe the features of a large cohort of patients with postoperative mediastinitis, with particular regard to Gram-negative bacteria (GNB), and assess their outcome. This bicentric retrospective cohort included all patients who were hospitalized in the Intensive Care Unit with mediastinitis after cardiac surgery during a 9-year period. Three hundred and nine patients developed a mediastinitis with a mean age of 65 years and a mean standard Euroscore of six points. Ninety-one patients (29.4%) developed a GNB mediastinitis (GNBm). Of the 364 pathogens involved, 103 GNB were identified. GNBm were more frequently polymicrobial (44% versus 3.2%; p <0.001). Being female was the sole independent risk factor of GNBm in multivariate analysis. Initial antimicrobial therapy was significantly more frequently inappropriate with GNBm compared with other microorganisms (24.6% versus 1.9%; p <0.001). Independent risk factors for inappropriateness of initial antimicrobial treatment were GNBm (OR = 8.58, 95%CI 2.53-29.02, p 0.0006), and polymicrobial mediastinitis (OR = 4.52, 95%CI 1.68-12.12, p 0.0028). GNBm were associated with more drainage failure, secondary infection, need for prolonged mechanical ventilation and/or use of vasopressors. Thirty-day hospital mortality was significantly higher with GNBm (31.9 % versus 17.0%; p 0.004). GNBm was identified as an independent risk factor of hospital mortality (OR = 2.31, 95%CI 1.16-4.61, p 0.0179).

[Stenting or coronary artery bypass surgery for triple vessel disease?]. / Maladie coronaire tritronculaire : angioplastie/stent ou pontages aortocoronaires ? Etat actuel et revue de la littérature.

This review was undertaken to objectively analyse the cumulated medical literature on techniques of myocardial revascularization (angioplasty, bare metal stenting, drug eluting stenting, coronary artery surgery) in multivessel coronary artery disease. Randomized trials, meta analyses and registries comparing these treatment modalities show a short and long term advantage of surgery over percutaneous techniques for angina recurrence and need for repeat revascularization, although mortality and myocardial infarction rate do not seem statistically different. Diabetes mellitus, chronic renal failure and female gender represent high risk subgroups. Data on drug eluting stents are to date limited to the short term; however, it does not seem that drug eluting stents have resolved the need for repeat revascularization. Stenting addresses focal lesion whereas future revascularization occurs on other coronary sites by progression of coronary disease. Cardiologists should objectively inform the consenting coronary multivessel disease patient on the risk of repeat revascularization inherent to percutaneous techniques and on the weight of actual data favouring surgery in multivessel disease.

[Prevention and treatment of atrial fibrillation after cardiac surgery]. / Prevention et traitement de la fibrillation atriale après chirurgie cardiaque.

The incidence of postoperative atrial fibrillation in cardiac surgery is still high despite major advances in anesthetic, pharmacological and surgical techniques. Its precise mechanism is still totally unknown. Postoperative atrial fibrillation increases length of stay as well as hospital costs. Rate of postoperative atrial fibrillation spontaneous conversion is high. Several protocols have been developed for prevention and/or treatment of postoperative atrial fibrillation. Beta-blockers, amiodarone and atrial pacing reduce.atrial fibrillation incidence as compared to placebo. On the other hand, amiodarone and propafenone achieve a high conversion rate of installed postoperative atrial fibrillation. However, among many pharmacological options, the best treatment is still to be defined.

Acute rupture of a left ventricular false aneurysm.

Left ventricular aneurysm develop when rupture of the free ventricular wall is contained by the inflammatory surrounding tissues. These false aneurysms rupture secondarily and should be treated soon after diagnosis. The diagnosis is suggested by echocardiography and confirmed by cardiac catheterization. Immediate surgery is recommended, with good survival in most reports. The patient presented in this report had ruptured his left ventricular false aneurysm before diagnosis. He was operated and had a good initial postoperative course. He died later from a severe pulmonary infection.

Mycotic aneurysm of the popliteal artery secondary to tuberculosis. A case report and review of the literature.

Mycotic aneurysms of the popliteal artery are rare; 33 cases have been reported in the literature. The treatment of choice is a large excision with extra-anatomic revascularization. In situ revascularization is sometimes possible. To the best of our knowledge, tuberculosis has never been reported as a causal factor of mycotic aneurysms of the popliteal artery. We report a case of a recurrent tuberculous false aneurysm of the popliteal artery. After 2 attempts at in situ revascularization, the femoral artery was ligated with no distal ischemia.

Renal artery pseudoaneurysm after blunt abdominal trauma.

Renal artery pseudoaneurysms are rare after blunt abdominal trauma; only 11 cases have been previously reported. Pseudoaneurysms are caused by decelerating injuries of the renal artery after major falls or automobile accidents. Patients may be asymptomatic for many years, and the pseudoaneurysm may expand and rupture before diagnosis or treatment. The patients in four untreated cases died. The diagnosis of renal artery pseudoaneurysm can be made by Doppler sonography, computerized tomography, renal perfusion imaging, or contrast angiography. Treatment requires either surgical or percutaneous intervention. Renal salvage was possible in five of the seven patients treated. We report two additional patients with successful outcomes after surgical intervention.