Daily multidisciplinary COVID-19 meeting: Experiences from a French university hospital.

OBJECTIVES: In March 2020, the World Health Organization declared the coronavirus disease 2019 (COVID-19) a pandemic. In absence of official recommendations, implementing daily multidisciplinary team (MDT) COVID-19 meetings was urgently needed. Our aim was to describe our initial institutional standard operating procedures for implementing these meetings, and their impact on daily practice. METHODS: All consecutive patients who were hospitalized in our institution due to COVID 19, from March 31 to April 15, 2020, were included. Criteria to be presented at MDT meetings were defined as a proven COVID-19 by PCR or strongly suspected on CT scan, requiring hospitalization and treatment not included in the standard of care. Three investigators identified the patients who met the predefined criteria and compared the treatment and outcomes of patients with predefined criteria that were presented during MDT meeting with those not presented during MDT meeting. COVID-19 MDT meeting implementation and adhesion were also assessed by a hospital medical staff survey. RESULTS: In all, 318 patients with confirmed or suspected COVID-19 were examined in our hospital. Of these, 230 (87%) were hospitalized in a COVID-19 unit, 91 (40%) of whom met predefined MDT meeting criteria. Fifty (55%) patients were presented at a MDT meeting versus 41 (45%) were not. Complementary exploration and inclusion in the CorImmuno cohort were higher in MDT meeting group (respectively 35 vs. 15%, P=0.03 and 80 versus 49%, P=0.0007). Prescription of hydrocortisone hemisuccinate was higher in group of patients not presented during MDT meeting (24 vs. 51%, P=0.007). Almost half of the patients fulfilling the inclusion criteria were not presented at MDT meeting, which can be partly explained by technical software issues. CONCLUSIONS: Multidisciplinary COVID-19 meetings helped implementing a single standard of care, avoided using treatments that were untested or currently being tested, and facilitated the inclusion of patients in prospective cohorts and therapeutic trials.

Knowledge and practices of Parisian family physicians for the management of men who have sex with men in the era of HIV pre-exposure prophylaxis.

INTRODUCTION: The optimal management of men who have sex with men (MSM) requires active involvement of family physicians (FP). We assessed knowledge and practices of Parisian FPs related to the management of MSM for sexually transmitted infections (STIs) and pre-exposure prophylaxis for HIV (PrEP). METHOD: We conducted an observational prospective study between June 20 and July 31, 2017, with a sample of FPs practicing in Paris. The questionnaire posted via the Google Form website included 42 questions on sexual health management of MSM patients. A statistical analysis was then performed. RESULTS: One hundred and four FPs took part in the study. The median age was 34 and 68% were women. Overall, 86.5% of FPs had already heard about PrEP, but only 36% of them were familiar with the indication for therapy and 77.9% of FPs declared to be willing to renew PrEP prescription. Overall, 89.4% of respondents declared to be willing to attend additional training on sexual health of MSM patients, including 73% on PrEP. CONCLUSION: FPs have an important role in the management of MSM patients. They showed strong interest in PrEP despite limited knowledge of indications and methods of administration. They declared to be willing to attend additional training for further involvement.

First year of pre-exposure prophylaxis implementation in France with daily or on-demand tenofovir disoproxil fumarate/emtricitabine.

BACKGROUND: In January 2016, the French Medicine Agency initiated a Temporary Recommendation for Use (TRU) to allow the use of oral intake of tenofovir disoproxil fumarate and emtricitabine for pre-exposure prophylaxis (PrEP) in adults at high risk of HIV. We report the results of the first year of PrEP implementation in France. METHODS: Data were collected by physicians using a secured web subject-monitoring interface, with two forms: an initiation form, with patients' baseline characteristics, and an HIV seroconversion form. Univariate and adjusted multivariate analysis using a logistic regression model were performed to identify baseline factors associated with on-demand PrEP regimen prescription. RESULTS: From 4 January 2016 to 28 February 2017, 3405 subjects were enrolled, with 2774 initiation forms completed; 98.1% were male and 96.9% were MSM. An on-demand regimen was prescribed to 57% of subjects. Older age (OR for participants older than 50 years = 1.76, 95% CI 1.35-2.3, P < 0.001) and site of prescription (OR of former IPERGAY sites = 2.28, 95% CI 1.84-2.83, P < 0.001) were associated with on-demand prescription. Those reporting sexually transmitted infection (STI) and condomless anal sex with at least two different partners were less likely to receive on-demand PrEP (OR = 0.68, 95% CI 0.57-0.82 and 0.75, 95% CI 0.57-0.98, respectively; P < 0.05 for all). Four breakthrough HIV infections were reported during the study, in the context of PrEP interruption or acute infection at the time of PrEP initiation. CONCLUSIONS: In a real-life setting in France, PrEP was used, either daily or on-demand, mostly by MSM, with breakthrough infections being rare.

HIV preexposure prophylaxis: An essential, safe and effective prevention tool for sexual health.

Preexposure prophylaxis of HIV with antiretroviral drugs is a prevention tool available in France since 2016, combined with the prevention methods already used (condoms, post-exposure treatment, rapid treatment of diagnosed HIV infections, etc.). It is targeted at populations at high risk of HIV infection, especially men who have sex with men, for whom traditional prevention methods are insufficient. We collected clinical research data, which resulted in the launch of preexposure prophylaxis in the United States and then elsewhere in the world, safety, tolerability and cost data, as well as ongoing research data (new molecules/methods of administration). We also provided an update of its use in France.

BK-virus infections: a literature review.

BK-virus is a very common polyomavirus in the global population, similar to the JC-virus responsible for Progressive Multifocal Leukoencephalopathy. BK-virus infections are an important diagnostic and therapeutic challenge in immuno-compromised patients, including: bone marrow transplant pediatric recipients in whom it may cause hemorrhagic cystitis, renal transplant recipients in whom it may cause interstitial nephropathy leading to graft loss, and in HIV infected patients in whom it may cause some types of encephalitis. Indeed, this poorly documented virus is responsible for infections with various clinical profiles, probably under-diagnosed, but could also be involved in the genesis of some cancers, especially cervix and prostate cancer. We reviewed the latest published data on this virus focusing on its possible pro-oncogenic properties. We also listed the diseases in which it is involved, with an emphasis on rare and insufficiently investigated entities. Finally, we studied the new tools available for diagnosis and treatment, and their importance in current practice.

Partial resurfacing arthroplasty of the femoral head in avascular necrosis. Methods, indications, and results.

The current study reports results using a partial surface replacement for osteonecrosis of the femoral head. The surgical technique, implant design, and instrumentation cause minor soft tissue disruption and require little bony resection. Thirty-seven prostheses were placed in 33 patients during the past 7 years. The mean age of the patients was 43 years (range, 24-59 years), and the preoperative Ficat classification was Stage III in 26 hips, Stage IV in 10, and Stage II in one hip. For the surviving prostheses, the mean followup was 49 months (range, 24-89 months). Of the 28 surviving implants, 24 continue to function well and the patients have excellent or good hip scores according to the Merle d'Aubigne system. There were nine failures, mainly attributable to the extension of the osteonecrosis. In comparison with alternative techniques, the operative surgery for partial surface replacement is straightforward, requiring little preoperative planning and immediate weightbearing postoperatively. Should failure occur, little bone stock loss is incurred and revision to a total hip replacement is as simple as primary hip arthroplasty.

[Original valgus tibial osteotomy by internal opening and without loss of bone contact. Technique and incidence of consolidation speed: a preliminary series of 33 cases]. / Ostéotomie tibiale de valgisation originale par ouverture interne sans perte de contact osseux. Technique et incidence sur la rapidité de consoliation: à propos des 33 premiers cas.

PURPOSE OF THE STUDY: We propose an original open wedge medial osteotomy of the upper tibia. This new technique, unlike conventional open wedge osteotomies, allows a large bone contact surface without requiring graft filling. MATERIAL AND METHOD: The new technique is based on two anterior and posterior hemi-osteotomies instead of the single osteotomy with the classical technique. The two hemi-osteotomies join laterally but start medially at very different heights on the tibia. The two hemi-osteotomies open a wedge but nevertheless lead to a very large bone contact due to the slippage in a frontal connecting frontal osteotomy. The technique uses a cutting guide to allow perfect orientation meeting the requirements of the operative plan. We studied prospectively the first 33 patients who underwent this new procedure in two centers (Jouvenet Clinic and Tenon Hospital, Paris). We report here the effect on healing time. RESULTS: There was one failure (retarded healing and partial loss of correction) due to incomprehension of the postoperative instructions. The other 32 cases consolidated in 45 days. No graft filling was needed.

Preliminary results of partial surface replacement of the femoral head in osteonecrosis.

We report our initial results using a partial surface replacement for osteonecrosis of the femoral head. We believe the prosthesis has the most minimalist design that has been reported either in Europe or North America. The surgical technique, implant design, and instrumentation cause minor soft tissue disruption and require little bony resection. We report the results of our first 25 prostheses performed over the past 5 years in 19 patients. The mean age was 42.5 years, (range, 24-59 years), with a preoperative Ficat classification of 15 hips, stage III; 9 hips, stage IV; and I hip, stage II. For the surviving prostheses, mean follow-up was 43 months, (range, 20-60 months). Of these 19 surviving implants, 15 continue to function well with excellent or good hip scores according to the Merle d'Aubigne system. We have had 6 failures: 1 owing to technical error, 4 owing to local tissue factors, and 1 owing to a progression of the osteonecrosis. The parameters for the use of this prosthesis are defined with our increasing experience, and the prosthesis is compared with other prosthetic implants available. In comparison with alternative techniques, the operative surgery is straightforward requiring little preoperative planning; immediate weight bearing is allowed postoperatively. Should failure occur, little bone stock loss is incurred, and revision to a total hip replacement is as simple as primary hip arthroplasty.

[Free transfer of the vascularized fibula in pseudarthrosis and femoral bone loss]. / Transfert libre de péroné vascularisé dans les pseudarthroses et pertes de substance fémorale.

The authors report their experience of femoral reconstruction by free fibular graft transfer. Twenty eight patients were operated on between 1977 and 1988. The average follow-up was 7 years and 3 months. The etiology of most of the cases was a post traumatic lesion (70 per cent). Loss of substance was found in 19 cases. 60 per cent of these were septic. The approach was usually posterior and vessels from the sciatic nerve were used. Union was obtained in 89 per cent of the cases. In 65 per cent of the cases union occurred in less than 1 year. In 1 out of 4 cases graft thickening was necessary and achieved by secondary bone grafts. The comparison of this technique with standard treatments evidenced a definite superiority of vascularized bone grafts in cases of septic pseudarthrosis and significant losses of bone.

[Reconstruction of loss of bony substance in limbs by free vascularized fibula transplant]. / Reconstruction des pertes de substances osseuses des membres par transfert libre de péroné vascularisé.

The authors present their experience of bone-loss reconstruction by a free vasculized fibular transfer. 62 cases were operated, with an average follow-up of 6 years (between 24 to 13 years). Studied were 15 upper limbs (10 humerus, 3 ulna, 2 radius), 28 femurs and 19 tibias. We found a male predominance: 46 cases and the average age was 33 years old. The etiology was often due to trauma: serious road traffic accidents (37 cases). 44 cases were septic and the average bone-loss was of 10 cm (between 4 cm to 30). The most frequent complications were due to fractures of the graft (10 cases) and stiffness (15 cases). Consolidation rate was of 87%: 8 were failures (3 upper limbs: 20% at femur level, 10% at tibia level). The average consolidation rate of the septic cases was of 81%, and the non-septic cases over 97.5%. It seems to be a good technique and in particular for septic cases using a basic orthopedic technique and microsurgical suture.

A noncemented total hip prosthesis.

Although total hip arthroplasty stabilized by cement has been a great step forward, loosening is becoming more and more frequent and constitutes a significant problem. This is a report of the design of a non-cemented prosthesis in which fixation of the prosthesis is secured by the in-growth of newly-formed bone into the irregularities of the metal. In more than 2000 cases with a follow-up of 5 1/2 years, this fixation design proves to be sound. The complications are relatively rare and the results are generally good.