Pharmacist-led medication reconciliation at patient discharge: a tool to reduce healthcare utilization? an observational study in patients 65 years or older.

BACKGROUND: Older patients often experience adverse drug events (ADEs) after discharge that may lead to unplanned readmission. Medication Reconciliation (MR) reduces medication errors that lead to ADEs, but results on healthcare utilization are still controversial. This study aimed to assess the effect of MR at discharge (MRd) provided to patients aged over 65 on their unplanned rehospitalization within 30 days and on both patients' experience of discharge and their knowledge of their medication. METHODS: An observational multicenter prospective study was conducted in 5 hospitals in Brittany, France. RESULTS: Patients who received both MR on admission (MRa) and MRd did not have significantly fewer deaths, unplanned rehospitalizations and/or emergency visits related to ADEs (OR = 1.6 [0.7 to 3.6]) or whatever the cause (p = 0.960) 30 days after discharge than patients receiving MRa alone. However, patients receiving both MRa and MRd were more likely to feel that their discharge from the hospital was well organized (p = 0.003) and reported more frequently that their community pharmacist received information about their hospital stay (p = 0.036). CONCLUSIONS: This study found no effect of MRd on healthcare utilization 30 days after discharge in patients over 65, but the process improved patients' experiences of care continuity. Further studies are needed to better understand this positive impact on their drug care pathway in order to improve patients' ownership of their drugs, which is still insufficient. Improving both the interview step between pharmacist and patient before discharge and the transmission of information from the hospital to primary care professionals is needed to enhance MR effectiveness. TRIAL REGISTRATION: NCT04018781 July 15, 2019.

Long-term outcomes and predictors of disabling disease in a population-based cohort of patients with incident Crohn's disease diagnosed between 1994 and 1997.

BACKGROUND: The identification of early prognostic factors during Crohn's disease (CD) remains needed for physician decision-making to minimize structural bowel damage, which this study aimed to assess in a population-based setting. METHODS: All incident cases of CD were prospectively registered from 1994 to 1997 in Brittany, a limited area of France. All charts of patients were reviewed from the diagnosis to the last clinic visit in 2015. Disabling CD course was defined according to the Saint-Antoine criteria. RESULTS: Among the 331 incident cases of CD, 272 (82%) were followed-up for a median time of 12.8 years. The cumulative probability of developing stricturing or fistulizing CD was 66% at 15 years, and 107 (39%) patients underwent surgery. The cumulative probabilities of immunosuppressant and TNF antagonist use at 15 years were 37% and 22%, respectively. The cumulative risks for disabling disease and bowel damage were 74% and 71% at 15 years, respectively. Systemic symptoms and perianal lesions at diagnosis were independently associated with a disabling disease course. Perianal disease and short disease extension were associated with the onset of bowel damage. Deep ulcers was not predictive of any outcome. CONCLUSIONS: A disabling disease course and bowel damage occurred early in the course of CD, which suggests the need for early diagnosis and early treatment, particularly for patients with systematic symptoms and perianal disease.

Natural History of Perianal Crohn's Disease: Long-term Follow-up of a Population-Based Cohort.

BACKGROUND AND AIMS: The natural history of perianal Crohn's disease (PCD) remains poorly described and is mainly based on retrospective studies from referral centers. The aim of this study was to assess the incidence, outcomes and predictors of the onset of PCD. METHODS: All incident cases of patients diagnosed with possible CD were prospectively registered from 1994 to 1997 in Brittany, a limited area in France. At diagnosis, the clinical features of perianal disease were recorded. All patient charts were reviewed from the diagnosis to the last clinic visit in 2015. RESULTS: Among the 272 out of 331 incident CD patients followed up, 51 (18.7%) patients had PCD at diagnosis. After a mean follow-up of 12.8 years, 93 (34%) patients developed PCD. The cumulative probabilities of perianal CD occurrence were 22%, 29%, and 32% after 1 year, 5 years, and 10 years, respectively. The cumulative probabilities of anal ulceration were 14%, and 19% after 1 year and 10 years, respectively. Extraintestinal manifestations were associated with the occurrence of anal ulceration. The cumulative probabilities of fistulizing PCD were 11%, 16%, and 19% after 1 year, 5 years, and 10 years, respectively. Extraintestinal manifestations, rectal involvement and anal ulceration were predictors of fistulizing PCD. The cumulative probability of developing anal stricture was 4% after 10 years. CONCLUSIONS: PCD is frequently observed during CD, in approximately one-third of patients. These data underline the need for targeted therapeutic research on primary perianal lesions (proctitis, anal ulceration) to avoid the onset of fistulizing perianal disease.

Transient Elastography Accurately Screens for Compensated Advanced Chronic Liver Disease in Patients With Ongoing or Recent Alcohol Withdrawal.

BACKGROUND & AIMS: Liver stiffness measurement by transient elastography (TE) is a promising method for staging fibrosis in alcohol-related liver disease, but uncertainties remain regarding the influence of alcohol consumption and thus the ideal timing for TE performance. We evaluated the performance of TE compared with liver biopsy to exclude compensated advanced chronic liver disease (cACLD) in patients hospitalized for alcohol detoxification. METHODS: Patients were recruited prospectively at 6 in-patient addiction centers in France. Eligible patients had increased aspartate aminotransferase levels, and no history or signs of overt cirrhosis. TE, histology, and biochemistry measurements were obtained within a median of 6 days after alcohol withdrawal. TE and biochemistry were repeated 1 and 2 months later. RESULTS: The study included 259 patients for per-protocol analysis, of whom 45 (17%) had cACLD. TE identified patients with high accuracy at inclusion and at the 1- and 2-month follow-up evaluation, with area under the curve values of 0.96 (95% CIs, 0.94-0.99), 0.96 (95% CIs, 0.92-0.99), and 0.93 (95% CIs, 0.85-1.00), respectively. In 84% of patients, cACLD was ruled out when liver stiffness was less than 10 kPa (negative predictive value, 99% (95% CIs, 98%-100%)) or ruled in when greater than 25 kPa (positive predictive value, 93% (95% CI, 83%-102%)). Algorithms based on aminotransferase levels and/or bilirubin did not add to the diagnostic performance of TE in this period. Among patients with initial liver stiffness of 10 to 25 kPa, more than half of those with no cACLD showed liver stiffness of less than 10 at 1- and 2-month follow-up testing. CONCLUSIONS: TE performed during the first 2 months after alcohol cessation is an excellent method for excluding alcohol-related cACLD. CLINICAL TRIAL NUMBER: NCT01789008.

Effectiveness of mRNA-BNT162b2, mRNA-1273, and ChAdOx1 nCoV-19 vaccines against COVID-19 in healthcare workers: an observational study using surveillance data.

OBJECTIVES: Healthcare workers (HCWs) at increased risk of coronavirus disease 2019 (COVID-19) were among the primary targets for vaccine campaigns. We aimed to estimate the protective efficacy of the first three COVID-19 vaccines available in Western Europe. METHODS: We merged two prospective databases that systematically recorded, in our institution: (a) HCWs positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by RT-PCR on nasopharyngeal samples, and (b) HCWs who received at least one dose of COVID-19 vaccine. We excluded HCWs with SARS-CoV-2 infection during the 6 months prior to the study. HCWs were categorized as non-vaccinated if they received no vaccine and until the first injection +13 days, partially vaccinated from the first injection +14 days to the second injection +13 days, and fully vaccinated thereafter. RESULTS: Of the 8165 HCWs employed in our institution, 360 (4.4%) tested positive for SARS-CoV-2 by RT-PCR during the study period (4th January to 17th May 2021). Incidence was 9.1% (8.2-10.0) in non-vaccinated HCWs, 1.2% (0.7-1.9) after one dose of ChAdOx1 nCoV-19, 1.4% (0.6-2.3) and 0.5% (0.1-1.0) after one and two doses of mRNA BNT162b2, 0.7% (0.1-1.9) and 0% after one and two doses of mRNA-1273 (p < 0.0001). Vaccine effectiveness (Cox model) was estimated at, respectively, 86.2% (76.5-91.0), 38.2% (6.3-59.2), and 49.2% (19.1-68.1) 14 days after the first dose for ChAdOx1 nCoV-19, mRNA-1273, and mRNA-BNT162b2, and 100% (ND) and 94.6% (61.0-99.2) 14 days after the second dose for mRNA-1273 and mRNA-BNT162b2. CONCLUSIONS: In this real-world study, the observed effectiveness of COVID-19 vaccines in HCWs was in line with the efficacy reported in pivotal randomized trials.

Whole-body MR imaging in suspected physical child abuse: comparison with skeletal survey and bone scintigraphy findings from the PEDIMA prospective multicentre study.

OBJECTIVES: To assess the contribution of whole-body magnetic resonance imaging (WBMRI) and bone scintigraphy (BS) in addition to skeletal survey (SS) in detecting traumatic bone lesions and soft-tissue injuries in suspected child abuse. METHODS: In this prospective, multicentre, diagnostic accuracy study, children less than 3 years of age with suspected physical abuse were recruited. Each child underwent SS, BS and WBMRI. A blinded first review was performed in consensus by five paediatric radiologists and three nuclear medicine physicians. A second review investigated discrepancies reported between the modalities using a consensus result of all modalities as the reference standard. We calculated the sensitivity, specificity and corresponding 95% confidence interval for each imaging modality (SS, WBMRI and BS) and for the combinations [SS + WBMRI] and [SS + BS]. RESULTS: One hundred seventy children were included of which sixty-four had at least one lesion. In total, 146 lesions were included. The sensitivity and specificity of each examination were, respectively, as follows: 88.4% [95% CI, 82.0-93.1] and 99.7% [95% CI, 99.5-99.8] for the SS, 69.9% [95% CI, 61.7-77.2] and 99.5% [95% CI, 99.2-99.7] for WBMRI and 54.8% [95% CI, 46.4-63.0] and 99.7% [95% CI, 99.5-99.9] for BS. Sensitivity and specificity were, respectively, 95.9% [95% CI, 91.3-98.5] and 99.2% [95% CI, 98.9-99.4] for the combination SS + WBMRI and 95.2% [95% CI, 90.4-98.1] and 99.4% [95% CI, 99.2-99.6] for the combination SS + BS, with no statistically significant difference between them. CONCLUSION: SS was the most sensitive independent imaging modality; however, the additional combination of either WBMRI or BS examinations offered an increased accuracy. KEY POINTS: • SS in suspected infant abuse was the most sensitive independent imaging modality in this study, especially for detecting metaphyseal and rib lesions, and remains essential for evaluation. • The combination of either SS + BS or SS + WBMRI provides greater accuracy in diagnosing occult and equivocal bone injuries in the difficult setting of child abuse. • WBMRI is a free-radiation technique that allows additional diagnosis of soft-tissue and visceral injuries.

Hypothermic Oxygenated Perfusion Improves Extended Criteria Donor Liver Graft Function and Reduces Duration of Hospitalization Without Extra Cost: The PERPHO Study.

Few studies have evaluated the efficacy or the cost of hypothermic oxygenated perfusion (HOPE) in the conservation of extended criteria donor (ECD) grafts from donation after brain death (DBD) donors during liver transplantation (LT). We performed a prospective, monocentric study (NCT03376074) designed to evaluate the interest of HOPE for ECD-DBD grafts. For comparison, a control group was selected after propensity score matching among patients who received transplants between 2010 and 2017. Between February and November 2018, the HOPE procedure was used in 25 LTs. Immediately after LT, the median aspartate aminotransferase (AST) level was significantly lower in the HOPE group (724UI versus 1284UI; P = 0.046) as were the alanine aminotransferase (ALT; 392UI versus 720UI; P = 0.01), lactate (2.2 versus 2.7; P = 0.01) There was a significant reduction in intensive care unit stay (3 versus 5 days; P = 0.01) and hospitalization (15 versus 20 days; P = 0.01). The incidence of early allograft dysfunction (EAD; 28% versus 42%; P = 0.22) was similar . A level of AST or ALT in perfusate >800UI was found to be highly predictive of EAD occurrence (areas under the curve, 0.92 and 0.91, respectively). The 12-month graft (88% versus 89.5%; P = 1.00) and patient survival rates (91% versus 91.3%; P = 1.00) were similar. The additional cost of HOPE was estimated at € 5298 per patient. The difference between costs and revenues, from the hospital's perspective, was not different between the HOPE and control groups (respectively, € 3023 versus € 4059]; IC, -€ 5470 and € 8652). HOPE may improve ECD graft function and reduce hospitalization stay without extra cost. These results must be confirmed in a randomized trial.

Interendoscopist variability in proximal colon polyp detection is twice higher for serrated polyps than adenomas.

AIM: To assess the interendoscopist variability in the detection of colorectal polyps according to their location and histological type. METHODS: This study was a retrospective analysis of prospectively collected data from a regional colorectal cancer (CRC) screening program; 2979 complete colonoscopies from 18 endoscopists were included. Variability in performance between endoscopists for detection of at least one adenoma (A), one proximal adenoma (PA), one distal adenoma (DA), and one proximal serrated polyp (PSP) was assessed by using multilevel logistic regression models. RESULTS: The observed detection rates among the 18 endoscopists ranged from 24.6% to 47.6% (mean = 35.7%) for A, from 19.1% to 39.0% (mean = 29.4%) for DA, from 6.0% to 22.9% (mean = 12.4%) for PA, and from 1.3% to 19.3% (mean = 6.9%) for PSP. After adjusting for patient-level variables (sex, age), the interendoscopist detection rates variability achieved a significant level for A, PA, and PSP but not for DA (P = 0.03, P = 0.02, P = 0.02 and P = 0.08, respectively). This heterogeneity, as measured by the variance partition coefficient, was approximately threefold higher for PA (6.6%) compared with A (2.1%), and twofold higher for PSP (12.3%) compared with PA. CONCLUSION: These results demonstrate significant interendoscopist variability for proximal polyp particularly for serrated polyps, but not for distal adenoma detection. These findings contribute to explain the decreased effectiveness of complete colonoscopies at preventing proximal CRCs and the need to carefully assess the proximal colon during scope procedure.

Frequency of and risk factors for the surgical resection of nonmalignant colorectal polyps: a population-based study.

BACKGROUND AND STUDY AIMS: The management of patients with colon polyps who are referred to surgery remains uncharacterized in a population-based setting. The aims of this study were to determine the frequency, risk factors, and outcomes of patients referred for surgical resection of colorectal polyps. PATIENTS AND METHODS: All patients who underwent a colonoscopy for positive fecal occult blood test in the setting of a population-based colorectal cancer screening program in France between 2003 and 2012 were analyzed. The primary outcome was the proportion of patients undergoing colorectal surgery for polyps without invasive carcinoma. Logistic regression analysis was applied to identify risk factors for surgical resection. RESULTS: Among 4251 patients with at least one colorectal polyp, 175 (4.1 %) underwent colorectal surgery. Risk factors for surgery included size, proximal polyp location, advanced histology (villous or high grade dysplasia), the endoscopy center, and colonoscopy performed during the first half of the study period. Subgroup analysis of 3475 colonoscopies performed by 22 endoscopists who performed at least 50 colonoscopies during the study period, identified the endoscopist as an additional risk factor. The adjusted proportions of referrals to surgery ranged from 0 to 46.6 % per endoscopist for polyps ≥ 20  mm (median 20.2 %). Overall, surgical complications occurred in 24.0 %, and one patient died following surgery (0.5 %). None of the 175 patients who underwent surgery were referred to a tertiary endoscopic center prior to surgery. CONCLUSIONS: In this population-based study, 4.1 % of patients with nonmalignant polyps were referred for surgical resection. The endoscopist was one important factor that was associated with surgical referral. To further decrease the proportion of inappropriate surgery in patients, endoscopists should refer their patients with large or difficult polyps to expert endoscopists prior to surgery.

Oral versus intravenous high-dose methylprednisolone for treatment of relapses in patients with multiple sclerosis (COPOUSEP): a randomised, controlled, double-blind, non-inferiority trial.

BACKGROUND: High doses of intravenous methylprednisolone are recommended to treat relapses in patients with multiple sclerosis, but can be inconvenient and expensive. We aimed to assess whether oral administration of high-dose methylprednisolone was non-inferior to intravenous administration. METHODS: We did this multicentre, double-blind, randomised, controlled, non-inferiority trial at 13 centres for multiple sclerosis in France. We enrolled patients aged 18-55 years with relapsing-remitting multiple sclerosis who reported a relapse within the previous 15 days that caused an increase of at least one point in one or more scores on the Kurtzke Functional System Scale. With use of a computer-generated randomisation list and in blocks of four, we randomly assigned (1:1) patients to either oral or intravenous methylprednisolone, 1000 mg, once a day for 3 days. Patients, treating physicians and nurses, and data and outcome assessors were all masked to treatment allocation, which was achieved with the use of saline solution and placebo capsules. The primary endpoint was the proportion of patients who had improved by day 28 (decrease of at least one point in most affected score on Kurtzke Functional System Scale), without need for retreatment with corticosteroids, in the per-protocol population. The trial was powered to assess non-inferiority of oral compared with intravenous methylprednisolone with a predetermined non-inferiority margin of 15%. This trial is registered with ClinicalTrials.gov, number NCT00984984. FINDINGS: Between Jan 29, 2008, and June 14, 2013, we screened 200 patients and enrolled 199. We randomly assigned 100 patients to oral methylprednisolone and 99 patients to intravenous methylprednisolone with a mean time from relapse onset to treatment of 7·0 days (SD 3·6) and 7·4 days (3·9), respectively. In the per-protocol population, 66 (81%) of 82 patients in the oral group and 72 (80%) of 90 patients in the intravenous group achieved the primary endpoint (absolute treatment difference 0·5%, 90% CI -9·5 to 10·4). Rates of adverse events were similar, but insomnia was more frequently reported in the oral group (77 [77%]) than in the intravenous group (63 [64%]). INTERPRETATION: Oral administration of high-dose methylprednisolone for 3 days was not inferior to intravenous administration for improvement of disability scores 1 month after treatment and had a similar safety profile. This finding could have implications for access to treatment, patient comfort, and cost, but indication should always be properly considered by clinicians. FUNDING: French Health Ministry, Ligue Française contre la SEP, Teva.

Predictive value of global longitudinal strain in a surgical population of organic mitral regurgitation.

BACKGROUND: Because of the lack of reliable echocardiographic parameters to predict recovery after surgery, the optimal timing of surgery for severe mitral regurgitation remains controversial. The aim of this study was to determine whether global longitudinal strain (GLS) recorded preoperatively could help in predicting left ventricular (LV) ejection fraction (LVEF) postoperatively. METHODS: A total of 88 patients (mean age, 63 ± 13 years; 59 men) with severe degenerative mitral regurgitation were included prospectively in this study. Rest echocardiography was performed before and 6 ± 1 months after mitral valve surgery. Patients were divided into two groups: group A (postoperative LVEF ≥ 50%) and group B (postoperative LVEF < 50%). RESULTS: In group B, patients had larger preoperative LV end-systolic diameters (21.6 ± 2.6 vs 19.2 ± 3.7 mm/m(2), P = .02) and impaired preoperative GLS (-17 ± 2.8% vs -19.6 ± 3.6%, P = .01), whereas there was no difference in preoperative LVEF. Preoperative LV end-systolic diameter ≥ 22 mm/m(2) and GLS < -18% were independent predictors of postoperative LV dysfunction. CONCLUSIONS: LV end-systolic diameter is a well-recognized prognostic marker. In addition, this study demonstrates the additive and independent predictive value of preoperative GLS for predicting postoperative LV dysfunction.

Neoplasia detection rates after positive fecal occult blood test results are not affected by endoscopy center: a population-based study.

BACKGROUND: We previously showed a significant variability in adenoma detection among colonoscopists who were participating in a mass screening program. The reasons for such variability remain largely unknown. OBJECTIVE: To study intercenter variations in neoplasia detection. DESIGN AND SETTING: Secondary analyses of colonoscopy findings from the 2 first rounds of a French screening program: logistic regressions and repeated-measures analyses of variance. MATERIAL: A total of 3487 colonoscopies performed by all 19 endoscopists who performed 30 examinations or more per round at 8 centers (6 private, 2 public). MAIN OUTCOME MEASUREMENTS: Probabilities of detecting 1, 2, or 3 or more adenomas, 1 adenoma 10 mm or larger, or colorectal cancer, as well as the corresponding adjusted (for patient age and sex) per-center detection rates. RESULTS: Endoscopy centers were not significant predictors of the probability of detecting any category of neoplasia with the exception of the 2 adenomas or more category (P < .005). The ranges of the adjusted detection rates for each of these categories were 33.1% to 43.1%, 11.1% to 21.6%, 3.6% to 8.1%, 16.3% to 23.6%, and 8.3% to 12.6%, respectively. When the colonoscopies that were performed by the 11 endoscopists who performed 30 examinations or more per center in 2 or more centers were separately analyzed, no intercenter statistically significant variability was observed with the exception of 1 endoscopist and the 1 adenoma category. In a subgroup of 1100 colonoscopies performed by 6 endoscopists who were working at the same 3 centers, intercenter variability was not statistically significant. LIMITATIONS: Type II error because of sample sizes. CONCLUSIONS: In our setting, intercenter variability did not explain interendoscopist variability for neoplasia detection rate.

Left atrial function assessed by trans-thoracic echocardiography in patients treated by ablation for a lone paroxysmal atrial fibrillation.

AIMS: Atrial fibrillation (AF) may induce three kinds of atrial remodelling: morphological, contractile, and electrical. Maintain of sinus rhythm is usually associated with left atrial (LA) volume decrease, but little is known about the evolution of its mechanical properties. We sought to explore LA mechanical and morphological remodelling in patients with lone paroxysmal-AF treated by catheter ablation (CA). METHODS AND RESULTS: We prospectively included 31 patients (56.4 ± 10 years). We also followed 15 age- and gender-matched controls to get normal values. Each patient had a complete echocardiography at baseline and at 3-month and 1-year follow-up. LA-anatomical reverse remodelling was documented: indexed LA volume decreased from 39 mL/m(2) at baseline to 31 mL/m(2) at 1 year (P < 0.001). However, it remained larger than controls (31 vs. 23 mL/m(2), P = 0.001). LA compliance improved (LA lateral systolic peaks of strain = 50 vs. 31%, P < 0.05) without reaching controls values as estimated by 50 vs. 81%, P < 0.05). LA contractility increased as highlighted by A'-peak velocity (10 cm/s at 1Y-F/up vs. 7.5 at baseline, P = 0.01) and LA late diastolic peaks of strain rate (septal: -3 vs. -1 s(-1), lateral: -3 vs. -1.4 s(-1), P < 0.05). We show a functional remodelling at 1 year, with most contractile parameters being comparable to controls, whereas LA compliance remains significantly altered. CONCLUSION: AF-CA could reverse LA anatomical and functional remodelling. Despite improvement, LA compliance remains altered after 1 year, probably reflecting irreversible fibrosis.

Yield of high-grade dysplasia based on polyp size detected at colonoscopy: a series of 2295 examinations following a positive fecal occult blood test in a population-based study.

PURPOSE: The aim was to determine the rate of high-grade dysplasia among patients with all adenomas, and its prevalence in patients with adenomas of different sizes in a well-defined population-based study. POPULATION AND METHODS: We performed a secondary analysis of the 2295 colonoscopies performed following a positive fecal occult blood test result during the first round of colorectal cancer screening in one French district. The rates of high-grade dysplasia were calculated for 3 size categories of adenoma (diminutive, or=10 mm). Predictive factors for high-grade dysplasia were assessed by univariate and multivariate analyses. RESULTS: A total of 1284 adenomas were detected in 784 subjects. High-grade dysplasia was present in 32.1% of the 784 subjects and in 2.7%, 16.0%, and 51.1% of those whose adenomas were diminutive, small, and large, respectively. Among subjects with no more than 2 small adenomas, the proportion of those with high-grade dysplasia was 12.4%. Both adenoma size and a villous component within adenomas were found to be independent predictive factors for high-grade dysplasia by multivariate analysis. CONCLUSIONS: Because of the high rate of high-grade dysplasia among small adenomas, our results reinforce the need to remove all small adenomas detected at colonoscopy. Furthermore, the results suggest that opting for CT colonography surveillance instead of colonoscopic removal among subjects with one or 2 small polyps revealed by CT colonography would have led to missed high-grade dysplasia in 12.4% of them.

Variations between endoscopists in rates of detection of colorectal neoplasia and their impact on a regional screening program based on colonoscopy after fecal occult blood testing.

BACKGROUND: There are few data about the performance variability among endoscopists participating to nationwide or regionwide colorectal cancer screening programs. OBJECTIVE: To assess the variability of neoplasia detection rates among endoscopists participating in a regional colorectal cancer screening program based on colonoscopy after biennial fecal occult blood testing (FOBT). DESIGN: Two rounds of colonoscopy were performed: round 1 took place in 2003 and 2004, and round 2 took place in 2005 and 2006. Secondary analysis of colonoscopy findings from the first 2 rounds was performed by using data drawn from all endoscopists who performed more than 30 colonoscopies in each round. Detection rates were adjusted for patient age and sex, and logistic regression analyses were conducted including these 2 variables and round number (1 or 2). SETTING: District of Ille-et-Vilaine in Brittany (population >900,000) between 2003 and 2007. MAIN OUTCOME MEASUREMENTS: The per-endoscopist adjusted rates of colonoscopies with at least 1, 2, or 3 adenomas, 1 adenoma 10 mm or larger, or a cancer. RESULTS: Among the 18 endoscopists who performed 3462 colonoscopies, the adjusted detection rates were in the following ranges: at least 1 adenoma, 25.4% to 46.8%; 2 adenomas, 5.1% to 21.7%; 3 adenomas, 2.7% to 12.4%; 1 adenoma 10 mm or larger, 14.2% to 28.0%; and cancer, 6.3% to 16.4%. Multivariate analyses showed that the endoscopist was not an independent predictor of cancer detection, but was an independent predictor of detecting adenomas, regardless of category; the R(2) of the models ranged from 6% to 13% only. LIMITATIONS: Other factors known to influence colorectal neoplasia occurrence and withdrawal time could not be taken into account. CONCLUSIONS: In a screening program with a high compliance rate with colonoscopy after FOBT, interendoscopist variability had no effect on cancer detection, but did influence identification of adenomas. The clinical impact of such findings merits further evaluation.

Clinical contributions of 64-slice computed tomography in the evaluation of cardiomyopathy of unknown origin.

BACKGROUND: Meta-analyses have confirmed the high performance of multislice computed tomography (MSCT) in coronary stenosis detection. Recent reports have described the study of left ventricular anatomy and function and coronary venous anatomy with MSCT. AIMS: We sought to compare, in patients with cardiomyopathy of unknown origin, the performance of MSCT versus angiography for significant coronary artery disease detection and versus transthoracic echocardiography (TTE) for left ventricular anatomy and function evaluation, and to assess its ability to characterize coronary venous anatomy. METHODS: Fifty-nine patients with cardiomyopathy (left ventricular ejection fraction [LVEF] less than or equal to 40%) of unknown origin, in sinus rhythm, underwent MSCT, TTE and coronary angiography. RESULTS: Twenty-four (3%) of 724 analysable coronary segments (97%) and 12 (20%) patients had significant coronary artery disease. MSCT sensitivity, specificity, and positive and negative predictive values for coronary artery disease detection were 87.5%, 98.5%, 67.7% and 99.6% in the per-segment assessment and 100%, 91%, 75% and 100% in the per-patient evaluation, respectively. Statistical analyses showed good agreement between MSCT and TTE in LVEF measurement (33+/-10% vs 32+/-11%, p=0.4, mean difference=0.7%, limits of agreement+/-13.6%) and a small LVED diameter overestimation (65.0+/-9.3mm vs 63.6+/-9.4mm, p=0.03). MSCT allowed detection of the posterolateral vein in 86% of cases. CONCLUSIONS: In selected patients presenting with idiopathic cardiomyopathy, MSCT is accurate for coronary artery disease detection and is a useful coronary venous imaging tool. MSCT studies of left ventricular function and morphology were mostly concordant with TTE measurements.

Interleukin-2 before antiretroviral therapy in patients with HIV infection: a randomized trial (ANRS 119).

BACKGROUND: Interleukin (IL)-2 increases CD4 T cell counts when combined with antiretroviral therapy (ART). Whether IL-2 alone can increase CD4 cell counts is unknown. METHODS: A total of 130 adults who had a CD4 cell count of 300-500 cells/microL (and, thus, were not eligible to receive ART) were randomized to receive either intermittent IL-2 therapy or no treatment. The primary end point was a drop in CD4 cell count to <300 cells/microL, initiation of ART, the occurrence of an AIDS-defining event, or death. RESULTS: Through week 96, 35% of the patients in the IL-2 arm and 59% in the control arm reached the primary end point (P = .008). Median changes from baseline in the IL-2 and control arms were +51 and -64 cells/microL, respectively, for CD4 cell count (P < .001) and were +0.02 and +0.04 log(10) copies/mL, respectively, for plasma viral load (P = .93). Among patients with a baseline viral load <4.5 log(10) copies/mL, 64% in the IL-2 arm and 10% in the control arm did not reach the primary end point through week 150 (P < .001), and the time to ART initiation was deferred by 92 weeks in the IL-2 arm. The incidences of an AIDS-defining event, death, and grade 3 or 4 adverse events were similar between study arms. CONCLUSION: IL-2 increased CD4 cell counts without affecting HIV replication and allowed the initiation of ART to be deferred. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00120185 .