Diagnosis, Treatment and Long-Term Management of Vitamin B12 Deficiency in Adults: A Delphi Expert Consensus.

Background/Objectives: Vitamin B12 deficiency can cause variable symptoms, which may be irreversible if not diagnosed and treated in a timely manner. We aimed to develop a widely accepted expert consensus to guide the practice of diagnosing and treating B12 deficiency. Methods: We conducted a scoping review of the literature published in PubMed since January 2003. Data were used to design a two-round Delphi survey to study the level of consensus among 42 experts. Results: The panelists agreed on the need for educational and organizational changes in the current medical practices for diagnosing and treating B12 deficiency. Recognition of clinical symptoms should receive the highest priority in establishing the diagnosis. There is agreement that the serum B12 concentration is useful as a screening marker and methylmalonic acid or homocysteine can support the diagnosis. Patient lifestyle, disease history, and medications can provide clues to the cause of B12 deficiency. Regardless of the cause of the deficiency, initial treatment with parenteral B12 was regarded as the first choice for patients with acute and severe manifestations of B12 deficiency. The use of high-dose oral B12 at different frequencies may be considered for long-term treatment. Prophylactic B12 supplementation should be considered for specific high-risk groups. Conclusions: There is a consensus that clinical symptoms need to receive more attention in establishing the diagnosis of B12 deficiency. B12 laboratory markers can support the diagnosis. The severity of clinical symptoms, the causes of B12 deficiency, and the treatment goals govern decisions regarding the route and dose of B12 therapy.

Medical Journals: Role, Place, Issues, and Future Challenges.

Society and humans are evolving at exponential speeds [...].

Nephrocalcinosis fortuitously discovered: the role of surreptitious self administration of diuretics.

Background: Furosemide is a drug widely used for several medical conditions and could be used without medical prescription. Furosemide-related nephrocalcinosis can occur regardless of age, although the risk is higher in premature infants. The defining characteristic of nephrocalcinosis is generalized calcium deposition in the kidney. The most useful imaging studies for evaluation are ultrasonography and computed tomography (more effective in detecting calcification). Case Presentation: A 32-year-old woman with a history of depressive syndrome was admitted for evaluation of fortuitously discovered nephrocalcinosis and hypokalemia. The studies performed revealed the presence of a metabolic alkalosis with discrete hyperreninism/hyperaldosteronism but normal ratio, normotension and urinary study showed elevated sodium, chloride, potassium and calcium fluctuating in different determinations. Surreptitious diuretic intake was suspected and urine analysis revealed doses equivalent to 80-120 mg. The patient was advised to discontinue all diuretic treatment; she was adequately supplemented with potassium and she was followed-up in outpatient clinics. During the follow-up, clinical and analytical improvement was noted, which led to the discontinuation of supplementation. Conclusion: Surreptitious diuretic intake is a clinical condition to rule out in patients with chronic hypokalemia, metabolic alkalosis with elevated urinary sodium and chloride. The relation between surreptitious diuretic intake and nephrocalcinosis has not been fully elucidated in adults.

Medical Journal, Readers, Success: An Inseparable Trinity.

At the start of this new year, the Editorial Board of the Journal of Clinical Medicine (J [...].

Gram-Negative ESKAPE Bacteria Surveillance in COVID-19 Pandemic Exposes High-Risk Sequence Types of Acinetobacter baumannii MDR in a Tertiary Care Hospital.

The interruption of bacteriological surveillance due to the COVID-19 pandemic brought serious consequences, such as the collapse of health systems and the possible increase in antimicrobial resistance. Therefore, it is necessary to know the rate of resistance and its associated mechanisms in bacteria causing hospital infections during the pandemic. The aim of this work was to show the phenotypic and molecular characteristics of antimicrobial resistance in ESKAPE bacteria in a Mexican tertiary care hospital in the second and third years of the pandemic. For this purpose, during 2021 and 2022, two hundred unduplicated strains of the ESKAPE group (Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii) were collected from various clinical sources and categorized by resistance according to the CLSI. An analysis of variance (ANOVA) complemented by the Tukey test was performed to search for changes in antimicrobial susceptibility profiles during the study period. Finally, the mechanisms of resistance involved in carbapenem resistance were analyzed, and the search for efflux pumps and high-risk sequence types in A. baumannii was performed by multilocus analysis (MLST). The results showed no changes in K. pneumoniae resistance during the period analyzed. Decreases in quinolone resistance were identified in E. coli (p = 0.039) and P. aeruginosa (p = 0.03). Interestingly, A. baumannii showed increases in resistance to penicillins (p = 0.004), aminoglycosides (p < 0.001, p = 0.027), carbapenems (p = 0.027), and folate inhibitors (p = 0.001). Several genes involved in carbapenem resistance were identified (blaNDM, blaVIM, blaOXA, blaKPC, blaOXA-40, and blaOXA-48) with a predominance of blaOXA-40 and the adeABCRS efflux pump in A. baumannii. Finally, MLST analysis revealed the presence of globally distributed sequence types (ST369 and ST758) related to hospital outbreaks in other parts of the world. The results presented demonstrate that the ESKAPE group has played an important role during the COVID-19 pandemic as nosocomial antibiotic-resistant pathogens and in particular A. baumannii MDR as a potential reservoir of resistance genes. The implications of the increases in antimicrobial resistance in pathogens of the ESKAPE group and mainly in A. baumannii during the COVID-19 pandemic are analyzed and discussed.

Symptomatic Postoperative Compressive Pneumocephalus After Cholecystectomy.

A 75-year-old woman with a history of chronic hydrocephalus due to stenosis of the aqueduct of Sylvius was examined at the emergency department for altered mental status. There was placement of a ventriculoperitoneal shunt in 1970 complicated by meningitis, leading to removal of the material and ventriculociternostomy as definitive treatment in 2004. About one month previously, she had undergone a laparoscopic cholecystectomy complicated by an intra-abdominal collection. Clinical examination at the emergency department revealed a Glasgow score of 8 (E3 V1 M4). In the emergency department the patient presented a tonic-clonic seizure before a cerebral CT scan was performed showing a massive compressive pneumocephalus, then a second seizure. The patient was finally admitted to the neurosurgery department and underwent surgery. LEARNING POINTS: Changes in mental status in a patient with a history of chronic hydrocephalus should alert clinicians to a possible complication.This case reflects the delayed diagnosis of a critically ill patient in the emergency department.

Prognostic Impact of the UMIPIC Program in the Follow Up in Patients with Heart Failure and Cardiorenal Syndrome.

BACKGROUND: Individuals suffering from heart failure (HF) and cardiorenal syndrome (CRS) represent a special group of patients considering their age, multiple health issues, and treatment challenges. These factors make them more susceptible to frequent hospital stays and a higher mortality rate. UMIPIC is a multidisciplinary care model program for patients with heart failure follow up provided by internists and nurses who are experts in this entity. Our study delved into the effectiveness of this specialized care program (UMIPIC) in mitigating these risks for HF and CRS patients. METHODS: We analyzed the medical records of 3255 patients diagnosed with HF and CRS types 2 and 4, sourced from the RICA registry. These patients were divided into two distinct groups: those enrolled in the UMIPIC program (1205 patients) and those under standard care (2050 patients). Using propensity score matching, we ensured that both groups were comparable. The study focused on tracking hospital admissions and mortality rates for one year after an HF-related hospital stay. RESULTS: Patients in the UMIPIC group experienced fewer hospital readmissions due to HF compared to their counterparts (20% vs. 32%; Hazard Ratio [HR] = 0.48; 95% Confidence Interval [95% CI]: 0.40-0.57; p < 0.001). They also showed a lower mortality rate (24% vs. 36%; HR = 0.64; 95% CI: 0.54-0.75; p < 0.001). Furthermore, the UMIPIC group had fewer total hospital admissions (36% vs. 47%; HR = 0.58; 95% CI: 0.51-0.66; p < 0.001). CONCLUSIONS: The UMIPIC program, centered on holistic and ongoing care, effectively reduces both hospital admissions and mortality rates for HF and CRS patients after a one-year follow-up period.

Assessing the Efficacy of the Modified SEGA Frailty (mSEGA) Screening Tool in Predicting 12-Month Morbidity and Mortality among Elderly Emergency Department Visitors.

INTRODUCTION: Rapid identification of frail elderly individuals upon admission to the emergency department is pivotal for enhancing their care and alleviating emergency room congestion. OBJECTIVE: This pilot study aims to explore the relationship between morbidity, mortality, and frailty, as assessed by the mSEGA scale, among individuals aged 65 years or older in the emergency department. METHODS: A retrospective cohort study was conducted at a single center. The pilot study included patients aged 65 and above who were admitted to Chaumont Hospital's emergency unit (Haute-Marne department) for medical and/or surgical reasons between 1 July 2017 and 31 January 2018. Data encompassed socio-demographic characteristics, medical profiles, and emergency department visit details. Outcomes for patients one year post-admission were obtained through consultation with their respective general practitioners. RESULTS: A total of 255 subjects participated, with a mean age of 82.1 ± 8.2 years. Primary admission reasons were falls (n = 51, 20.0%), digestive issues (excluding hemorrhage) (n = 30, 11.8%), and "other" causes (n = 61, 23.9%). Among participants, 78 (30.6%) scored ≤8 on the mSEGA frailty scale, 49 (19.2%) scored 9 to 11, and 125 (50.2%) scored ≥12. Concerning post-emergency department outcomes, 152 patients (59.6%) were hospitalized, while 103 (40.4%) were discharged. No deaths were reported during the study period, and vital status was known for all subjects at the one-year mark. At that point, 63 out of 255 patients had passed away, with 30 of them being readmitted to the emergency department either before or at the time of their one-year death. The 12-month survival rate analysis based on frailty status revealed a significant difference. Low-frailty patients exhibited a survival rate of 87.2% (95% CI; [77.5-92.9]), whereas frail/very frail patients had a survival rate of 70.0% (95% CI; [62.7-76.2]). Similarly, the 12-month readmission-free survival rate demonstrated statistically significant disparities. Low-frailty patients had a rate of 76.9% (95% CI; [65.9-84.8]), compared to 51.4% (95% CI; [43.8-58.5]) for very frail patients. CONCLUSION: Utilizing the mSEGA frailty scale in the Emergency Department could provide crucial prognostic insights, highlighting significant differences in 12-month survival and readmission-free survival rates based on frailty status.

Malignant hypercalcemia revealing a diffuse large B-cell lymphoma in a patient with a previous diagnosis of chronic myelomonocytic leukemia: An uncommon hematological coexistence.

A 76-year-old patient previously admitted to the cardiology department for replacement of a right ventricular lead on a double-chamber pacemaker was admitted to the internal medicine department 15 days after for bronchopneumopathy. His past medical history was relevant for Type 2 diabetes mellitus, heart failure due to dilated hypokinetic heart disease, transcatheter aortic valve implantation (TAVI), and chronic myelomonocytic leukemia (CMML-0) diagnosed in 2021. Twenty-four hours after admission, the patient's general condition deteriorated abruptly, with the onset of drowsiness and psychomotor retardation. Laboratory exams revealed hypercalcemia at 4.18 mmol/L. Intensive hydration, calcitonin, and zoledronic acid were initiated and the patient was transferred to the nephrology intensive care unit where he underwent two sessions of hemodialysis to normalize serum calcium levels before readmission to internal medicine. Laboratory exams revealed low parathyroid hormone, normal 1-25-OH vitamin D, and increased parathyroid hormone-related peptide. Thoracoabdominal and positron emission tomography (PET) scan showed diffuse abdominopelvic peritoneal carcinosis associated with low-grade pleural effusion and multiple supra- and sub-diaphragmatic adenopathies, leading to a search for a solid tumor. The patient's clinical condition worsened leading to a transfer to the intensive care unit. The biopsy of a peritoneal carcinosis nodule confirmed the diagnosis of diffuse large B-cell lymphoma. Specific treatments were unsuccessful and the patient expired.

[Study of the links between type 2 diabetes and geriatric criteria]. / Étude des liens entre diabète de type 2 et critères gériatriques.

Type 2 diabetes in the elderly remains a major concern for all healthcare professionals and is itself considered a "global pandemic". Its prevalence is high and will continue to increase in years to come, becoming more and more prevalent in the elderly and very elderly. We offer a general summary of the work focusing on the links between type 2 diabetes and geriatric criteria.

Clinical Characteristics and Prognostic Impact of Short Physical Performance Battery in Hospitalized Patients with Acute Heart Failure-Results of the PROFUND-IC Registry.

BACKGROUND: Most patients diagnosed with heart failure (HF) are older adults with multiple comorbidities. Multipathological patients constitute a population with common characteristics: greater clinical complexity and vulnerability, frailty, mortality, functional deterioration, polypharmacy, and poorer health-related quality of life with more dependency. OBJECTIVES: To evaluate the clinical characteristics of hospitalized patients with acute heart failure and to determine the prognosis of patients with acute heart failure according to the Short Physical Performance Battery (SPPB) scale. METHODS: Observational, prospective, and multicenter cohort study conducted from September 2020 to May 2022 in patients with acute heart failure as the main diagnosis and NT-ProBNP > 300 pg. The cohort included patients admitted to internal medicine departments in 18 hospitals in Spain. Epidemiological variables, comorbidities, cardiovascular risk factors, cardiovascular history, analytical parameters, and treatment during admission and discharge of the patients were collected. Level of frailty was assessed by the SPPB scale, and dependence, through the Barthel index. A descriptive analysis of all the variables was carried out, expressed as frequencies and percentages. A bivariate analysis of the SPPB was performed based on the score obtained (SPPB ≤ 5 and SPPB > 5). For the overall analysis of mortality, HF mortality, and readmission of patients at 30 days, 6 months, and 1 year, Kaplan-Meier survival curves were used, in which the survival experience among patients with an SPPB > 5 and SPPB ≤ 5 was compared. RESULTS: A total of 482 patients were divided into two groups according to the SPPB with a cut-off point of an SPPB < 5. In the sample, 349 patients (77.7%) had an SPPB ≤ 5 and 100 patients (22.30%) had an SPPB > 5. Females (61%) predominated in the group with an SPPB ≤ 5 and males (61%) in those with an SPPB > 5. The mean age was higher in patients with an SPPB ≤ 5 (85.63 years). Anemia was more frequent in patients with an SPPB ≤ 5 (39.5%) than in patients with an SPPB ≥ 5 (29%). This was also seen with osteoarthritis (32.7%, p = 0.000), diabetes (49.6%, p = 0.001), and dyslipidemia (69.6%, p = 0.011). Patients with an SPPB score > 5 had a Barthel index < 60 in only 4% (n = 4) of cases; the remainder of the patients (96%, n = 96) had a Barthel index > 60. Patients with an SPPB > 5 showed a higher probability of survival at 30 days (p = 0.029), 6 months (p = 0.031), and 1 year (p = 0.007) with (OR = 7.07; 95%CI (1.60-29.80); OR: 3.9; 95%CI (1.30-11.60); OR: 6.01; 95%CI (1.90-18.30)), respectively. No statistically significant differences were obtained in the probability of readmission at 30 days, 6 months, and 1 year (p > 0.05). CONCLUSIONS: Patients admitted with acute heart failure showed a high frequency of frailty as assessed by the SPPB. Patients with an SPPB ≤ 5 had greater comorbidities and greater functional limitations than patients with an SPPB > 5. Patients with heart failure and a Barthel index > 60 frequently presented an SPPB < 5. In daily clinical practice, priority should be given to performing the SPPB in patients with a Barthel index > 60 to assess frailty. Patients with an SPPB ≤ 5 had a higher risk of mortality at 30 days, 6 months, and 1 year than patients with an SPPB ≤ 5. The SPPB is a valid tool for identifying frailty in acute heart failure patients and predicting 30-day, 6-month, and 1-year mortality.

Organizational Benefits of Ultra-Low-Dose Chest CT Compared to Chest Radiography in the Emergency Department for the Diagnostic Workup of Community-Acquired Pneumonia: A Real-Life Retrospective Analysis.

Background and Objectives: Chest radiography remains the most frequently used examination in emergency departments (ED) for the diagnosis of community-acquired pneumonia (CAP), despite its poor diagnostic accuracy compared with ultra-low-dose (ULD) chest computed tomography (CT). However, although ULD CT appears to be an attractive alternative to radiography, its organizational impact in ED remains unknown. Our objective was to compare the relevant timepoints in ED management of CT and chest radiography. Materials and Methods: We conducted a retrospective study in two ED of a University Hospital including consecutive patients consulting for a CAP between 1 March 2019 and 29 February 2020 to assess the organizational benefits of ULD chest CT and chest radiography (length of stay (LOS) in the ED, time of clinical decision after imaging). Overlap weights (OW) were used to reduce covariate imbalance between groups. Results: Chest radiography was performed for 1476 patients (mean age: 76 years [63; 86]; 55% men) and ULD chest CT for 133 patients (mean age: 71 [57; 83]; 53% men). In the weighted population with OW, ULD chest CT did not significantly alter the ED LOS compared with chest radiography (11.7 to 12.2; MR 0.96 [0.85; 1.09]), although it did significantly reduce clinical decision time (6.9 and 9.5 h; MR 0.73 [0.59; 0.89]). Conclusion: There is real-life evidence that a strategy with ULD chest CT can be considered to be a relevant approach to replace chest radiography as part of the diagnostic workup for CAP in the ED without increasing ED LOS.

Early Hospital Discharge Using Remote Monitoring for Patients Hospitalized for COVID-19, Regardless of Need for Home Oxygen Therapy: A Descriptive Study.

AIM: Since beds are unavailable, we prospectively investigated whether early hospital discharge will be safe and useful in patients hospitalized for COVID-19, regardless of their need for home oxygen therapy. POPULATION AND METHODS: Extending the initial inclusion criteria, 62 patients were included and 51 benefited from home telemonitoring, mainly assessing clinical parameters (blood pressure, heart rate, respiratory rate, dyspnea, temperature) and peripheral saturation (SpO2) at follow-up. RESULTS: 47% of the patients were older than 65 years; 63% needed home oxygen therapy and/or presented with more than one comorbidity. At home, the mean time to dyspnea and tachypnea resolutions ranged from 21 to 24 days. The mean oxygen-weaning duration was 13.3 ± 10.4 days, and the mean SpO2 was 95.7 ± 1.6%. The nurses and/or doctors managed 1238 alerts. Two re-hospitalizations were required, related to transient chest pain or pulmonary embolism, but no death occurred. Patient satisfaction was good, and 743 potential days of hospitalization were saved for other patients. CONCLUSION: The remote monitoring of vital parameters and symptoms is safe, allowing for early hospital discharge in patients hospitalized for COVID-19, whether or not home oxygen therapy was required. Oxygen tapering outside the hospital allowed for a greater reduction in hospital stay. Randomized controlled trials are necessary to confirm this beneficial effect.

[Use of the Stopp/Start version 2 tool in an acute geriatric unit]. / Usage de l'outil Stopp/Start version 2 en unité gériatrique aiguë.

INTRODUCTION: Inappropriate drug prescriptions (IP) lead to a high risk of adverse effects, especially for the elderly. Their detection is essential - which can be done using therapeutic lists, including the Stopp/Start scale version 2. METHODS: Observational study - from August 1, 2016, to November 30, 2016, in an advanced geriatric unit at Rouen University Hospital - using the Stopp/Start version 2 list. RESULTS: Eighty-five patients were included, with a ratio of 1.36 women per every man. Sixty-one patients (71.8%) had prescriptions for more than five drugs. The average Charlson comorbidity score was 6.05. One hundred ninety-one IPs were found. Classes E and G (kidney function and respiratory system prescriptions, respectively) were not uncovered. Fifty-four Stopp criteria - 66% of Stopp criteria - never emerged during our study. Using the 34 Start criteria, 187 omissions of prescriptions were found. Classes F and G (endocrine system and urogenital system drugs, respectively) were not observed at any time. Ten criteria were never seen (B3/C1/C4/C5/E6/E7/F1/G1/G2/G3). Nineteen criteria were mentioned less than three times - i.e., in approximately 10% of omissions. CONCLUSION: Our study is part of an approach to protecting the elderly. A significant number of IP and prescription drug omissions were uncovered using this Stopp/Start version 2 tool.

Focal Myositis of the Sternocleidomastoid Muscle: A Rare and Uncommon Cause of Cervical Mass.

We report on a 70-year-old male patient admitted to the internal medicine department for evaluation of a right cervical mass. He had been treated with antibiotics as an outpatient by his primary care doctor. Upon admission the patient was asymptomatic, but within a few hours his cervical mass enlarged; this enlargement was confined to the right sternocleidomastoid muscle. Complete blood investigations including serology and autoimmunity were negative. The neck scan and MRI were in favour of myositis. No other lesions were found either in the nasal fibre-optic exam or in the thoracic-abdominal-pelvic scan. The biopsy of the muscle showed a lymphoplasmacytic inflammatory infiltrate of the perimysium. The diagnosis of focal myositis was made. The patient clinically improved during hospitalisation with complete resolution of symptoms without any specific intervention. LEARNING POINTS: A thorough clinical examination is essential in the evaluation and characterisation of cervical masses.The diagnostic approach must be rigorous in order not to ignore potentially serious diseases.A high level of clinical suspicion is needed in the diagnosis of focal myositis.

Evaluation of Nutritional Status in an Acute Geriatric Unit: Retrospective Study and Analysis of Frailty Syndrome.

INTRODUCTION: The aim of our study is to evaluate the nutritional status of patients in an acute geriatric unit. METHODS: Patients included in the study were hospitalized in an acute geriatric unit over a period of 6 months. The nutritional status of each patient was evaluated with anthropometric measurements (the BMI and MNA scales), and biological measurements (albumin). Frailty was evaluated using three scales: the Fried scale, the CFS and the modified SEGA scale. RESULTS: A total of 359 patients were included, comprising 251 women (70%) with an average age of 85.28 years. The study showed that 102 elderly subjects were considered undernourished according to the BMI scale, 52 subjects were undernourished according to the MNA scale, and 50 subjects were undernourished according to their albumin levels. The relationships between undernutrition and frailty syndrome studied in our work show that elderly subjects who are undernourished according to the BMI and MNA scales are significantly frail according to Fried and Rockwood, whereas those who are undernourished according to their albumin levels are significantly frail according to Fried and the modified SEGA scale. CONCLUSION: The relationship between undernutrition and the frailty syndrome is close, and their joint screening is necessary, whether on an outpatient or in-hospital basis, in order to prevent negative events related to comorbidities and geriatric syndromes.

A Real-World Cost-Effectiveness Study Evaluating Imaging Strategies for the Diagnostic Workup of Renal Colic in the Emergency Department.

Introduction Both non-contrast Computed Tomography (CT) and ultrasound (US) are used for the diagnosis of renal colic in the emergency department (ED). Although US reduces radiation exposure, its diagnostic accuracy is inferior to that of CT. In this context, data regarding the cost and organizational impact of these strategies represent essential elements in the choice of imaging; however, they remain poorly documented. Aim of the study The aim of this study was to compare the costs and effectiveness of diagnostic workup by US and CT for patients consulting with renal colic in the ED. Methods We conducted a monocentric real-life retrospective study of patients consulting for a renal colic in an ED between 1 July 2018 and 31 December 2018. We estimated length of stay (LOS), total hospital costs at 60 days including ED, and initial and repeat admissions. Patients with initial US in the ED were compared to patients with initial CT using inverse probability weighting of the propensity score calculated from demographic variables, vital parameters, and clinical presentation. We calculated the incremental cost effectiveness ratio as the difference in costs by the difference in LOS. The variability of the results was assessed using non-parametric bootstrapping. Results In this study, of the 273 patients included, 67 were patients assessed with US and 206 with CT. The average costs were €1159 (SD 1987) and €956 (SD 1462) for US and CT, respectively, and the ED LOS was 8.9 [CI 95% 8.1; 9.4] and 8.7 [CI 95% 7.9; 9.9] hours for US and CT, respectively. CT was associated with a decreased LOS by 0.139 [CI 95% -1.1; 1.5] hours and was cost-saving, with a €199 [CI 95% -745; 285] reduction per patient. Conclusion When imaging is required in the ED for suspected renal colic as recommended, there is real-life evidence that CT is a cost-effective strategy compared to US, reducing costs and LOS in the ED.

Two-Years Follow-Up of Symptoms and Return to Work in Complex Post-COVID-19 Patients.

INTRODUCTION: Many COVID-19 patients present with severe long-lasting symptoms. They might benefit from a coordination team to manage such complex situations, but late efficacy still needs to be determined. POPULATION AND METHODS: Out of 105 contacts, 45 patients had two phone consultations separated by personalized support 15 and 22 months, respectively, after COVID infection. Self-reported symptoms, feelings of improvement and ability to return to work allowed us to determine the efficacy of the therapeutic strategy proposed. RESULTS: Unlike what was expected, many post-COVID-19 patients directly contacted the coordination team and had significant pre-existing comorbidities. Despite exercise, respiratory, olfactory rehabilitations, cognition/speech therapy and/or psychological support, the more frequent self-reported symptoms (fatigue, neurocognitive disorders, muscles and joint pain) did not resolve. However, dyspnea, anxiety and chest pain were significantly reduced. Finally, 2/3 of the patients felt some degree of improvement and returned to work either partially or fully, but 1/3 remained complaining of symptoms and out of work as late as 22 months after COVID occurrence. All patients greatly appreciated the second phone consultation. CONCLUSIONS: In such complex situations, besides early and adapted rehabilitations and psychological help allowing better symptom management, relatively simple actions such as a phone call might be very useful to reduce patients' feelings of abandonment.

A Real-World Cost-Effectiveness Analysis of Rivaroxaban versus Vitamin K Antagonists for the Treatment of Symptomatic Venous Thromboembolism: Lessons from the REMOTEV Registry.

Background and objectives: Venous thromboembolism (VTE) represents a health and economic burden with consequent healthcare resource utilization. Direct oral anticoagulants (DOACs) have emerged as the mainstay option for VTE treatment but few data exist on their cost-effectiveness as compared to the standard therapy (vitamin K antagonists (VKAs)). This study aimed to assess the cost-effectiveness of rivaroxaban compared to VKAs in VTE treatment by calculating the incremental cost effectiveness ratio (ICER). Materials and methods: We conducted a prospective observational study based on the REMOTEV registry, including patients hospitalized for VTE from 23 October 2013 to 31 July 2015, to evaluate the impact of the anticoagulant treatment (DOACs versus VKAs) on 6-month complications: major or clinically relevant non-major bleeding, VTE recurrence and all-cause death. Rivaroxaban was the only DOAC prescribed in this study. The ICER was calculated as the difference in costs divided by the difference in effectiveness. Results: Among the 373 patients included, 279 were treated with rivaroxaban (63.1 ± 17.9 years old; 49% men) and 94 with VKAs (71.3 ± 16.6 years old; 46% men). The mean cost was EUR 5662 [95% CI 6606; 9060] for rivaroxaban and EUR 7721 [95% CI 5130; 6304] for VKAs, while effectiveness was 0.0586 95% CI [0.0114; 0.126] for DOACs and 0.0638 [95% CI 0.0208; 0.109] for VKAs. The rivaroxaban treatment strategy was dominant with costs per patient EUR 2059 lower [95% CI -3582; -817] and a higher effectiveness of 0.00527 [95% CI -0.0606; 0.0761] compared to VKAs. Conclusions: This study provides real-world evidence that rivaroxaban is not only an efficient and safe alternative to VKAs for eligible VTE patients, but also cost-saving.

Peripheral Blood Mononuclear Cells Mitochondrial Respiration and Superoxide Anion after Heart Transplantation.

INTRODUCTION: The mitochondrial function of circulating peripheral blood mononuclear cells (PBMCs) is an interesting new approach to cardiac diseases. Thus, PBMC's mitochondrial respiration decreases in relation to heart failure severity. However, no data are available on heart-transplanted patients (Htx). POPULATION AND METHODS: We determined PBMCs mitochondrial respiration by high-resolution respirometry (Oroboros Instruments) and superoxide anion production using electron paramagnetic resonance (Bruker-Biospin) in 20 healthy subjects and 20 matched Htx and investigated clinical, biological, echocardiographic, coronarography and biopsy characteristics. RESULTS: PBMCs mitochondrial respiratory chain complex II respiration was decreased in Htx (4.69 ± 0.84 vs. 7.69 ± 1.00 pmol/s/million cell in controls and Htx patients, respectively; p = 0.007) and complex IV respiration was increased (24.58 ± 2.57 vs. 15.68 ± 1.67 pmol/s/million cell; p = 0.0035). Superoxide anion production was also increased in Htx (1.47 ± 0.10 vs. 1.15 ± 0.10 µmol/min; p = 0.041). The leucocyte-to-lymphocyte ratio was increased in Htx, whom complex II correlated with leucocyte number (r = 0.51, p = 0.02) and with the left ventricular posterior wall peak early diastolic myocardial velocity (r = -0.62, p = 0.005). Complex IV was increased in the two patients with acute rejection and correlated negatively with Htx's isovolumetric relation time (r = -0.45, p = 0.045). DISCUSSION: Although presenting with normal systolic function, Htx demonstrated abnormal PBMC's mitochondrial respiration. Unlike immunosuppressive therapies, subclinical diastolic dysfunction might be involved in these changes. Additionally, lymphopenia might reduce complex II, and acute rejection enhances complex IV respirations. CONCLUSION: PBMC's mitochondrial respiration appears modified in Htx, potentially linked to cellular shift, mild diastolic dysfunction and/or acute rejection.