Reliability and reproducibility of the American Association for the Surgery of Trauma scaling for renal injury and impact on radiologic follow-up.

INTRODUCTION: The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) is the most used classification for renal trauma. It determines the radiologic monitoring, only recommended for high-grade injuries. The aim of this study was to assess the subjectivity of AAST scaling and its impact on short-term follow-up. METHODS: We retrospectively reviewed all patients with blunt renal injuries admitted at a university hospital between 2010 and 2015. Computed Tomography (CT) scan were analyzed and injuries graded according to AAST OIS independently by a senior radiologist, a senior urologist who was blind to clinical data and a resident urologist. Grading disagreements were analyzed collegially to obtain a final rating. The agreement of AAST scaling was evaluated through the Cohen's Kappa coefficient. RESULTS: Ninety-seven patients had 101 renal injuries: low grade in 58.4% (11.9% grade I, 17.8% grade II, 28.7% grade III) and high grade in 41.6% of cases (23.6% grade IV and 17.8% grade V). The agreement was fair with Kappa coefficient at 0.36. The agreement was moderate in severity sub-division analysis (low or high grade): Kappa coefficient at 0.59. There was a disagreement in 49.5% between the senior urologist's and the senior radiologist's ratings. Those differences brought to a severity group change and radiologic follow-up modification in 34% (n=17). CONCLUSION: AAST OIS for renal trauma suffers from subjectivity but is improved by severity sub-group analysis. This subjectivity influences the radiologic follow-up but could be reduced by collegiate rating. LEVEL OF EVIDENCE: 4.

Plasma apolipoprotein C1 concentration is associated with plasma triglyceride concentration, but not visceral fat, in patients with type 2 diabetes.

INTRODUCTION: Apolipoprotein C1 (apoC1) is likely to play an important role in triglyceride (TG) metabolism. Mice overexpressing human apoC1 present decreased adipose tissue stores. This study aimed to determine whether apoC1 concentration influences fat mass and distribution and liver fat content (LFC) in patients with type 2 diabetes (T2D). METHODS: ApoC1 concentrations were measured by ELISA in 113 T2D patients and 56 normolipidaemic-normoglycaemic subjects. Visceral and subcutaneous fat areas were determined by single-slice axial T1-weighted magnetic resonance imaging (MRI), while LFC was measured by hydrogen-1 ((1)H) MR spectroscopy. RESULTS: ApoC1 concentrations were higher in T2D patients than in normolipidaemic-normoglycaemic subjects (P<0.0001), and did not correlate with visceral or subcutaneous fat areas, but significantly correlated with TG (P<0.0001) and LFC (P=0.02) in T2D patients. However, the correlation between apoC1 and LFC was lost after adjusting for TG. ApoC1 concentration was also significantly higher in T2D patients with TG<1.5mmol/L than in control subjects (P<0.0001), although both groups had similar TG levels. On multivariate analysis performed in T2D patients with TG<1.5mmol/L and control subjects, apoC1 concentration was independently and positively associated with type 2 diabetes (P<0.0001) and TG levels (P=0.03). CONCLUSION: This study reports, for the first time, that apoC1 is increased in T2D patients and is significantly correlated with TG, whereas no association was found between apoC1 and adipose tissue. This indicates that, in T2D, apoC1 may play a role in TG metabolism, but is unlikely to modulate fat mass and distribution. This increased apoC1 concentration in T2D patients is not only explained by the increased TG level in T2D patients.

Clinical and economic impact of drug eluting beads in transarterial chemoembolization for hepatocellular carcinoma.

WHAT IS KNOWN AND OBJECTIVE: Drug eluting beads (DEBs) theoretically improve the efficacy and safety of transarterial chemoembolization (TACE) in hepatocellular carcinoma (HCC). Nonetheless, their economic profile has not been assessed. Our retrospective before/after study aimed to compare efficacy, safety and economic profile of two strategies of TACE without (Period 1) or with the possibility of using DEBs (Period 2). METHODS: All HCC patients treated by TACE in our hospital between March 2006 and May 2013 were included. Economic analyses were performed from the French Public Health Insurance point of view according to the French Diagnosis-Related Group prospective payment system and from the analytic accountability. RESULTS AND DISCUSSION: One hundred and sixty-one patients were included. Median time to treatment failure and overall survival were 13.1 and 23.8 months in Period 1 vs. 14.1 and 30.2 months in Period 2 (P = 0.45 and P = 0.40). Mean hospital durations and tariffs were 14.9 ± 7.7 days and € 11 472 ± 5901 in Period 1 vs. 12.4 ± 8.4 days and € 7654 ± 4625 in Period 2 (P = 0.03 and P < 10(-4) ). WHAT IS NEW AND CONCLUSION: The possibility of using DEBs did not improve the prognosis in HCC patients treated by TACE. Nonetheless, it had a better medico-economic profile.

Measurement of interatrial dyssynchrony using tissue Doppler imaging predicts functional capacity and cardiac involvement in systemic sclerosis.

OBJECTIVES: We aimed to assess the prevalence of interatrial electromechanical dyssynchrony in systemic sclerosis (SSc) patients, and to study the correlation between interatrial delay and standard follow-up parameters. METHODS: Forty consecutive patients with SSc were studied. Classical echocardiographic measurements were obtained, including indices of left ventricular (LV) systolic and diastolic function, right ventricular function, and pulmonary artery pressure (PAP). Left atrial (LA) function was studied using volume measurements. The interatrial mechanical (IAMD) delay was obtained by measuring the time delay between the peak atrial velocities at the lateral tricuspid and mitral annuli using tissue Doppler imaging. A cut-off value of 35 ms was chosen to define the presence of a significant interatrial delay. The IAMD was compared to NYHA class, six-minute walking test (6MWT), NT proBNP levels, and the carbon monoxide diffusion capacity over alveolar volume ratio (DLCO/VA), as well as to classical echocardiographic parameters. RESULTS: Forty percent of patients were found to have significant interatrial dyssynchrony with an IAMD of 35 ms or more. Patients with interatrial dyssynchrony were more symptomatic, had a shorter 6MWT, higher NT proBNP levels, and a lower DLCO/VA compared with those without dyssynchrony. Regarding conventional echocardiographic parameters, increased IAMD was associated with more pronounced LV diastolic dysfunction, LA enlargement and dysfunction, altered RV function, and higher PAP. CONCLUSIONS: IAMD correlated with all of the standard follow-up parameters in SSc, and is probably a sensitive marker of LA involvement. This easy to measure parameter should be added to the routine echocardiographic assessment of these patients.

Randomisation and sample size for clinical audit on infection control.

Clinical audit is both a part of clinical governance and an essential component of infection prevention and control. It is frequently performed on a proportion of the target population. The sample should represent the source population and be sufficient for statistical analysis. In a hospital, infection control practices are likely to be quite similar within the same clinical area (cluster effect). This must be taken into consideration when calculating the necessary number of patients. Sample size is determined by the desired level of precision for estimating the compliance rate, or by the difference between observed and expected rates, or on the difference before and after implementation of interventions. To estimate the hospital-wide compliance rate without additional costs we suggest focusing the audit on a large number of wards, even if fewer observations within each ward are obtained, rather than auditing a large number of practices on a restricted number of wards.

[Evolution of the number of rotavirus and respiratory syncytial virus infections in children hospitalised in a French university hospital between 1998 and 2005]. / Évolution du nombre d'infections àRotavirus et à virus respiratoire syncytial chez les enfants hospitalisés au CHU de Dijon entre 1998 et 2005.

AIM: Respiratory syncytial virus (RSV) and Rotavirus infections represent up to 30% of cross infections in pediatric units. As they are a major public health problem, we studied their evolution and distribution at the Dijon University Hospital. POPULATION AND METHODS: This exhaustive retrospective study included children under 15 with a new Rotavirus or RSV infection who were hospitalised at the Dijon University Hospital between 1998 and 2005. The general trend was determined by using moving averages, and the Spearman correlation coefficient r(s) was calculated. RESULTS: From 1998 to 2005, 1886 new RSV (n=981) or Rotavirus (n=905) infections were identified in hospitalised children. The number of the infections decreased significantly, both for RSV (r(s)=-0.71 ; p<0.0001) and for Rotavirus (r(s)=-0.77 ; p<0.0001). Almost half of Rotavirus infections were nosocomial (46.3%) vs 5.3% of RSV infections, p<0.0001. There was no significant difference in the proportion of RSV nosocomial infections between the epidemic and non-epidemic period (4.9% of nosocomial infections vs 7.1% respectively, p=0.25). Rotavirus nosocomial infections were less frequent in epidemic period (41.6%) than in non-epidemic period (54.6%); p=0.0002. CONCLUSION: RSV and Rotavirus infections significantly decreased between 1998 and 2005. Proportion of RSV or Rotavirus infections didn't increase in epidemic period, which could be explained both by an increased attention from healthcare professionals and by the effectiveness of hygiene measures taken.

[Disposable vs reusable laryngeal mask airway: a cost-minimization analysis]. / Masques laryngés à usage unique vs réutilisable : une étude de minimisation de coûts.

JUSTIFICATION: According to French regulations concerning the risk of Creutzfeldt-Jakob disease transmission, traceability procedures of all sterile medical devices which need to be reused are mandatory. Despite sterilization processes, the reusable laryngeal mask airway (LMA) prion disease transmission remains possible. As a result, the disposable LMA has been introduced. OBJECTIVE: Assuming clinical equivalence was achieved, the cost of disposable vs reusable LMA was studied in a university hospital. STUDY DESIGN: A Cost-minimization analysis of disposable vs reusable laryngeal mask airway was realised. METHODS: Disposable LMA cost was calculated as the sum of product cost and elimination cost. Reusable LMA were autoclaved after hospital purchasing in two separate sterilizing processing units of the same hospital. Reusable LMA cost was determined combining materiel and labor costs. RESULTS: The reusable LMA cost depended on the sterilizing processing unit concerned and varied between 9.59 Euros and 9.69 vs 8.38 Euros for the single-use LMA. CONCLUSION: With the cost savings made possible by use of disposable LMA in both labor and consumables, this practice should be considered.

[Analysis of variation in delivered dose in diagnostic and therapeutic cerebral angiography]. / Analyse des variations de la dose délivrée au patient en angiographie cérébrale diagnostique et thérapeutique.

OBJECTIVES: Analysis of dose-area product (DAP) in cerebral angiography, according to the type of pathology and technique used. MATERIALS AND METHODS: Use of dosimetric and clinical data resulting from 84 diagnostic cerebral angiograms and 32 cerebral embolizations. RESULTS: The diagnostic angiography data were divided into three categories: A/ When a secondarily embolized aneurysm was diagnosed: n=17. B/ When the final diagnosis was an arteriovenous malformation (AVM): n=10. C/ In the case where the diagnosis was neither AVM, nor aneurysm to embolize: n=57. The cerebral embolizations were classified in two sub-groups: K/ When the embolization immediately followed the diagnostic angiogram: n=15. L/ When the embolization of the aneurysm took place 24 to 48H after the angiography: n=17. The mean DAP of group B containing the AVM is higher than mean DAP values in groups A and C, because of the increased cinegraphic time. There is a strong correlation between the duration of the fluoroscopy and the DAP (n=116; r=0.931; p<0.0001). Addition of runs in the group L contributes to the augmentation of the exposure time (significant difference in time: p=0.0054) and thus with the fact that DAP L>DAPK. CONCLUSION: Radiation dose during diagnostic cerebral angiography is increased in the presence of AVM. DAP of embolizations are higher when diagnostic and therapeutic phases are separated in time.

Changes in bone density in patients with ankylosing spondylitis: a two-year follow-up study.

The objectives of the study were to determine the 2 year rate of bone changes in patients with ankylosing spondylitis (AS) and, whether bone loss is related to physical impairment, systemic inflammation. and therapy. Consecutive outpatients fulfilling the modified New York criteria for AS were included. Baseline assessment included age, disease duration, treatment, clinical, radiologic and laboratory data. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were determined every 6 months. Persistent systemic inflammation was defined as mean ESR > or = 28 mm/h or mean CRP > or = 15 mg/l. Bone mineral density (BMD) at the lumbar spine and femoral neck was measured by dual-energy X-ray absorptiometry, at baseline and year 2. Statistical analysis compared the baseline and 24 month follow-up BMD data, and determined whether baseline data, and persistent systemic inflammation during the 2 years, were related to the 24 month percentage changes in BMD. Fifty-four patients (35 men, 19 women; mean age 37.3 +/- 11.3 years, mean disease duration 12.4 +/- 8.6 years) were included. After 2 years, BMD did not change at the lumbar spine (+0.75% +/- 3.5, p = 0.23), and decreased at the femoral neck (-1.6% +/- 4, p = 0.006). The 24 month percentage change in femoral neck BMD was related to persistent systemic inflammation, defined using ESR (mean percentage change -4.1% +/- 5.7 and -1.2% +/- 3.9 in patients with and without persistent inflammation; respectively; p = 0.007). These results suggest that persistent inflammation might be an etiologic factor of bone loss in AS.

[Epidemiology of viral nosocomial infections in pediatrics]. / Epidémiologie des infections nosocomiales virales en pédiatrie.

Nosocomial viral infections account for at least 5% of the total of NI and reach 23% in pediatric wards. The nosocomial infection (NI) incidence rate varies from 0.59 to 0.72 per 100 patients in pediatric wards. Many viruses have been associated with NI in pediatric wards. Rotavirus and respiratory syncytial virus (RSV) are the most frequent. Other viruses frequently identified are: calicivirus, adenovirus, astrovirus, influenza et para-influenza, rhinovirus and coronavirus. Asymptomatic infections occur frequently. The period of communicability varies and depends on the virus. It often begins before the clinical signs appear and ends after the healing. Viral shedding may be intermittent. Children and hospital environment and less frequently hospital staff are the main source for the virus. Poor handwashing results in direct spread to patient or self-inoculation even for respiratory viruses like RSV and rhinovirus. The main risk factors for NI are prolonged hospital stay, past history of prematurity and low age. Immunocompromised patients constitute a special high-risk group. Understaffing is also a risk factor. Minimal infective doses depend on the route of inoculation and the kind of virus. Low doses are for example sufficient for rotavirus, adenovirus and calicivirus. Viral inactivation is all the more easy when there is an envelope. Handwashing and appropriate isolation (technical and geographical) are the mainstay of prevention of viral NI. Vaccines are promising, especially for rotavirus.

HCV infection and diabetes mellitus: influence of the use of finger stick devices on nosocomial transmission.

An increased prevalence of hepatitis C virus (HCV) infection in patients with diabetes mellitus has suggested a link between these two conditions and the possibility of patient-to-patient HCV transmission during hospital admissions in diabetes units. We investigated the prevalence of HCV antibodies in 259 patients with diabetes mellitus consecutively admitted to our diabetic unit in 1998. The control group was composed of 14,100 volunteer blood donors. We divided the diabetic patients into two groups according to their HCV antibody status and also analysed patients for the following variables: age, disease duration, diabetes treatment, previous hospital admissions in a diabetes unit and use of finger stick devices. Anti-HCV antibodies were detected in 8 diabetic patients and 6 blood donors (3.09% vs 0.04%, p < 0.001). No differences were observed between anti-HCV-positive and anti-HCV-negative diabetic patients in terms of mode of treatment, previous hospital admissions in a diabetic unit and use of finger stick devices for capillary blood sampling. Our findings indicate that these medical practices play no role in nosocomial transmission of HCV in diabetic patients.

Testing the proportional hazards assumption in medical survival studies--application to a population-based study of acute myeloid leukaemia.

BACKGROUND: In the analysis of survival data using the Cox proportional hazard model, it is assumed that the magnitude of mortality risk for a predictor variable remains proportional over time. The time-dependent linear model and the piece-wise proportional hazard model (two or four intervals) take into account the variation of the risk over the entire follow-up period. METHOD: The three existing models were applied to a series of 266 patients with acute myeloid leukaemia (AML), diagnosed between 1980 and 1992 and recorded by the Registry of Hematopoietic Neoplasms in Côte d'Or, France. RESULTS: A non-proportional effect of age, period of diagnosis, whether the illness was primary or secondary and French-American-British (FAB) subtype was found significant. In particular, the effect of M2 versus M4-M5 subtypes was revealed by the non-proportional analyses, although this effect was non-significant using the Cox model. CONCLUSIONS: The clinical explanation of the variation of these effects over time is discussed, for example, relating the increase over time of the positive effect of the period of diagnosis to therapeutic improvements. Confirmation of these results on an independent data set is required.

Does hepatitis C virus co-infection accelerate clinical and immunological evolution of HIV-infected patients?

OBJECTIVE: To study the influence of hepatitis C virus (HCV) co-infection on clinical and immunological evolution of HIV-infected patients. DESIGN: A longitudinal study of HIV-infected individuals with or without HCV infection, identified at the Infectious Diseases Department of Dijon University Hospital and enrolled in a historical cohort, was performed. METHODS: One hundred and nineteen HIV-infected people co-infected with HCV and 119 matched individuals infected with HIV alone were included in the cohort (median participation time 3 years; range, 2 months to 11.5 years). Clinical progression was defined as one or more of the following: a 30% decrease in the Karnofsky index; a 20% loss of body weight; an AIDS-defining illness (for non-AIDS patients); death (except by accident, suicide or overdose). Immunological progression was defined as a 50% decrease in the initial CD4 T-cell count (for patients with an initial count > 100 x 10(6) cells/l). Effects of HCV co-infection were evaluated using Kaplan-Meier survival analysis and significance was tested using univariate (log-rank and Peto's tests) and multivariate methods (Cox's model). RESULTS: In univariate analysis, immunological progression was not statistically different between the HCV-positive group and the HCV-negative group, whereas clinical progression was significantly faster in HCV-positive patients (P < 0.005, log-rank test). In a multivariate Cox model, clinical progression remained significantly associated with infection by HCV [hazard ratio (HR), 1.64; 95% confidence interval (CI), 1.06-2.55; P < 0.05]. Stratified multivariable analysis retained HCV as a significant prognostic factor of clinical progression (HR, 10.9; 95% CI, 1.09-109.3; P < 0.05) and immunological progression (HR, 2.31; 95% CI, 1.16-4.62; P < 0.02) for patients with an initial CD4 count above 600 x 10(6) cells/l. CONCLUSIONS: Clinical progression is more rapid in HIV-HCV co-infected patients than in HIV-seropositive patients are not infected by HCV. The prognostic value of HCV infection for both clinical and immunological progression is significant at early stages of HIV infection. These findings may argue for active management of hepatitis C infection in co-infected individuals, especially for asymptomatic patients whose CD4 count is above 600 x 10(6) cells/l, to predict and prevent accelerated progression of HCV and HIV diseases.

Prophylactic administration of a complementarity-determining region derived from a neutralizing monoclonal antibody is effective against respiratory syncytial virus infection in BALB/c mice.

Immunotherapy with antibodies against respiratory syncytial virus (RSV) is a treatment option given the absence of any vaccine or other available satisfactory treatment. We selected one of our monoclonal antibodies, RS-348, that is highly neutralizing. We showed that a single peptide (PEP3H) derived from complementarity-determining region 3 (CDR3) of its heavy chain was capable of neutralizing the virus in vitro. When intranasally administered 24 h before challenge, this peptide protected BALB/c mice against RSV lung infection. These results indicate that a single CDR can be effective against RSV infection.