MACVIA-LR (Fighting Chronic Diseases for Active and Healthy Ageing in Languedoc-Roussillon): A Success Story of the European Innovation Partnership on Active and Healthy Ageing.

The Région Languedoc Roussillon is the umbrella organisation for an interconnected and integrated project on active and healthy ageing (AHA). It covers the 3 pillars of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA): (A) Prevention and health promotion, (B) Care and cure, (C) and (D) Active and independent living of elderly people. All sub-activities (poly-pharmacy, falls prevention initiative, prevention of frailty, chronic respiratory diseases, chronic diseases with multimorbidities, chronic infectious diseases, active and independent living and disability) have been included in MACVIA-LR which has a strong political commitment and involves all stakeholders (public, private, patients, policy makers) including CARSAT-LR and the Eurobiomed cluster. It is a Reference Site of the EIP on AHA. The framework of MACVIA-LR has the vision that the prevention and management of chronic diseases is essential for the promotion of AHA and for the reduction of handicap. The main objectives of MACVIA-LR are: (i) to develop innovative solutions for a network of Living labs in order to reduce avoidable hospitalisations and loss of autonomy while improving quality of life, (ii) to disseminate the innovation. The three years of MACVIA-LR activities are reported in this paper.

A reappraisal of ICU and long-term outcome of allogeneic hematopoietic stem cell transplantation patients and reassessment of prognosis factors: results of a 5-year cohort study (2009-2013).

Epidemiology and prognosis of complications related to allogeneic hematopoietic stem cell transplant (HSCT) recipients requiring admission to intensive care unit (ICU) have not been reassessed precisely in the past few years. We performed a retrospective single-center study on 318 consecutive HSCT patients (2009-2013), analyzing outcome and factors prognostic of ICU admission. Among these patients, 73 were admitted to the ICU. In all, 32 patients (40.3%) died in ICU, 46 at hospital discharge (63%) and 61 (83.6%) 1 year later. Survivors had a significantly lower sequential organ failure assessment (SOFA) score, serum lactate and bilirubin upon ICU admission. Catecholamine support, mechanical ventilation (MV) and/or renal replacement therapy during ICU stay, a delayed organ support and an active graft versus host disease (GvHD) significantly worsen the outcome. By multivariate analysis, the worsening of SOFA score from days 1 to 3, the need for MV and the occurrence of an active GvHD were predictive of mortality. In conclusion, the incidence of HSCT-related complications requiring an admission to an ICU was at 22%, with an ICU mortality rate of 44%, and 84% 1 year later. A degradation of SOFA score at day 3 of ICU, need of MV and occurrence of an active GvHD are main predictive factors of mortality.

[Appropriate medication prescribing in older people]. / Bon usage des médicaments chez le sujet âgé.

Drug-induced adverse effects are one of the main avoidable causes of hospitalization in older people. Numerous lists of potentially inappropriate medications for older people have been published, as national and international guidelines for appropriate prescribing in numerous diseases and for different age categories. The present review describes the general rules for an appropriate prescribing in older people and summarizes, for the main conditions encountered in older people, medications that are too often under-prescribed, the precautions of use of the main drugs that induce adverse effects, and drugs for which the benefit to risk ratio is unfavourable in older people. All these data are assembled in educational tables designed to be printed in a practical pocket format and used in daily practice by prescribers, whether physicians, surgeons or pharmacists.

[Phenotypic heterogeneity and phenotype-genotype correlations in dystrophinopathies: Contribution of genetic and clinical databases]. / Variabilité phénotypique et corrélations génotype-phénotype des dystrophinopathies : contribution des banques de données.

The objective of this work was to study the natural history of dystrophinopathies and the genotype-phenotype correlations made possible by the development of the clinical part of the French DMD database. The collection of 70,000 clinical data for 600 patients with an average longitudinal follow-up of 12years enabled clarification of the natural history of Duchenne and Becker muscular dystrophies and clinical presentations in symptomatic females. We were able to specify the phenotypic heterogeneity of motor, orthopedic and respiratory involvements (severe, standard and intermediary form), of the cardiac disorder (severe, standard or absent cardiomyopathy, absence of correlation between motor and cardiac involvements), and of brain function (mental deficiency in the patients with Becker muscular dystrophy, psychopathological disorders in dystrophinopathies). Phenotypic variability did not correlate with a specific mutational spectrum. We propose a model of phenotypic analysis based on the presence or not of muscular and cardiac involvements (described by age at onset and rate of progression) and brain involvement (described by the type and the severity of the cognitive impairment and of the psychological disorders). The methodology developed for the DMD gene can be generalized and used for other databases dedicated to genetic diseases. Application of this model of phenotypic analysis for each patient and further development of the database should contribute substantially to clinical research providing useful tools for future clinical trials.

[Anaesthetic management of brain-dead for organ donation: impact on delayed graft function after kidney transplantation]. / Pratiques anesthésiques pour prélèvement d'organes chez le sujet en mort encéphalique et pronostic du greffon rénal.

BACKGROUND: The aim of this study was to report current anaesthetic management brain-dead organ donors and to assess its impact on delayed kidney graft function (DGF). METHODS: To achieve this retrospective multicenter study, brain-dead patient records were analysed for the years 2005 to 2007. Expanded donor criteria, length of stay in ICU, duration of brain death, respect of recommended cold ischemia time, preoperative and intraoperative management, type of anaesthesia, hemodynamic and respiratory parameters during organ retrieval, and impact of anaesthesia on DGF were analysed. RESULTS: One hundred and forty-nine out of 165 files were available. Sixty-two percent of donors received anaesthetic drugs. There were no differences in demographic characteristics between the anaesthesia group (group A) and the no-anaesthesia group (group NA). In group NA, the mean arterial pressure (MAP)>65 mm Hg was more frequent (53% vs. 29%, P<0.01), but did not differ for maximal MAP. In group A, maximal heart rate was higher (120 vs. 105b/min, P=0.02) and donors received significantly more colloids (P<0.01). Independent risk factors of DGF included absence of hydroxyethyl starch infusion during the preoperative period and mechanical ventilation without PEEP. CONCLUSION: During organ retrieval, 62% of organ donors received anaesthetic drugs. Use of anaesthesia lead to lower MAP requiring more fluid challenge with colloids but did not influence the DGF.

Skeletal muscle effects of electrostimulation after COPD exacerbation: a pilot study.

Muscle dysfunction is a major problem in chronic obstructive pulmonary disease (COPD), particularly after exacerbations. We thus asked whether neuromuscular electrostimulation (NMES) might be directly useful following an acute exacerbation and if such a therapy decreases muscular oxidative stress and/or alters muscle fibre distribution. A pilot randomised controlled study of NMES lasting 6 weeks was carried out in 15 in-patients (n=9 NMES; n=6 sham) following a COPD exacerbation. Stimulation was delivered to the quadriceps and hamstring muscles (35 Hz). Primary outcomes were quadriceps force and muscle oxidative stress. At the end of the study, quadriceps force improvement was statistically different between groups (p=0.02), with a significant increase only in the NMES group (median (interquartile range) 10 (4.7-11.5) kg; p=0.01). Changes in the 6-min walking distance were statistically different between groups (p=0.008), with a significant increase in the NMES group (165 (125-203) m; p=0.003). NMES did not lead to higher muscle oxidative stress, as indicated by the decrease in total protein carbonylation (p=0.02) and myosin heavy chain carbonylation (p=0.01) levels. Finally, we observed a significant increase in type I fibre proportion in the NMES group. Our study shows that following COPD exacerbation, NMES is effective in counteracting muscle dysfunction and decreases muscle oxidative stress.

[Ecthyma gangrenosum and Pseudomonas aeruginosa septicemia in intensive care unit]. / Ecthyma gangrenosum et septicémie àPseudomonas aeruginosa en réanimation.

We report a case of a Pseudomonas aeruginosa septicemia complicated by a septic shock after chemotherapy for pulmonary cancer. Bilateral legs necrotic purpura corresponding to echtyma gangrenosum lesions (erythematous inflammatory halo, positive bacteriologic cutaneous biopsy) was noted 48 h previous to the shock. Echtyma gangrenosum manifestation should alert physician to P. aeruginosa septicemia risk and can be useful to guide probabilist antibiotherapy.

[Antifungal treatments of candidemia in non-neutropenic patients: evaluation of practice in intensive care units]. / Traitements antifongiques des candidémies chez les patients non neutropéniques : évaluation des pratiques en réanimation.

OBJECTIVE: The authors had for objective to assess systemic antifungal treatment for candidemia in non-neutropenic patients, in intensive care units (ICU), and compare the results with French 2004 recommendations. STUDY DESIGN: A retrospective multicenter study (nine ICU in two teaching hospitals) was made. PATIENTS AND METHOD: Thirty-eight non-neutropenic patients with at least one positive blood culture for Candida who had received systemic antifungal treatment were included between May 2004 and September 2007. RESULTS: Thirty-nine cases of candidemia were analyzed. The median age was 54.5 (21-80), the median SAPS II score at admission was 44 (20-79), the median duration of stay in ICU was 22.5 days (2-82), and the death rate was 45%. Candida albicans was identified in 69% of the cases. Eight percent of Candida sp. isolates were resistant or susceptible dose-dependent (S-DD) to fluconazole. Before identification, fluconazole, caspofungin, voriconazole, and amphotericin B were used in 74%, 15%, 5%, and 5% of cases respectively. After identification and antifungal susceptibility determination, fluconazole was used in 68% of cases, caspofungin in 24% of cases, any formulation of amphotericin B in 6% of cases, voriconazole in 3% of cases. The French recommendations were applied in 71% of cases before identification and in 68% of cases after identification and antifungal susceptibility determination. CONCLUSION: The main causes of non-compliance to recommendations were the use of fluconazole in patients previously exposed to azole agents, the use of caspofungin in hemodynamically unstable patients, and the absence of therapeutic desescalade.

Reduction of the severe sepsis or septic shock associated mortality by reinforcement of the recommendations bundle: a multicenter study.

INTRODUCTION: We determined whether the implementation of a bundle of 10 recommendations leads to the reduction of mortality in ICU patients with severe sepsis or septic shock. METHODS: All patients with severe sepsis or septic shock during two consecutive phases: a 6-month quality control period (observational) and secondly a 6-month intervention period based on the implementation of a bundle of 10 recommendations adapted from the Surviving Sepsis Campaign guidelines (initial bacteriological samples and initiating antibiotics, measurement of arterial lactate, volume expansion > or =20 ml/kg, targeted mean arterial pressure > or =65 mmHg and the assessments of central venous pressure and Scv(O2); glucose control, low doses of corticosteroids, a tidal volume < or =8 ml/kg in mechanically ventilated patients with ALI; adequate use of recombinant human activated protein C) were evaluated in 15 ICUs. The primary endpoint was the 28-day mortality rate and the secondary endpoint was the compliance with the recommendations of the care bundle. MEASUREMENT AND RESULTS: Four hundred and forty-five patients (230 and 215 in the observational and intervention periods, respectively) were included. In the two periods, the patients had similar characteristics. The 28-day mortality rate significantly decreased from 40% in the observational period to 27% in the intervention period (P=0.02). According to each recommendation, compliance with the care bundle was achieved in 9 to 100% of patients. CONCLUSION: The implementation of a care bundle adapted from the Surviving Sepsis Campaign guidelines decreases the 28-day mortality rate in patients with severe sepsis and/or septic shock.

Quality assessment in surgical care departments: proposal for a scoring system in terms of structure and process.

OBJECTIVE: To build a score able to reflect and rank surgical departments according to a definition of "quality" in terms of structure and process. METHODS: Collaborative design of a quality score in the framework of the French clinical research project NosoQual. Feasibility and observational study in 46 surgical departments visited between November 2002 and March 2003 according to standardised procedures. A bibliographic review followed by expert consultations, a field test, analysis and a final reconsideration leading to the definition of a consensual score. RESULTS: 138 variables comprised the score. They were classified into seven dimensions, each representing a different aspect of quality of care in surgery. According to the threshold and weight attributed to every variable, scores were calculated for each department. The average level of achievement of the scores varied from 42% to 71% of theoretical maxima. The variability of the scores related to the seven dimensions was larger and more significant than the one expressed by the overall score (coefficient of variation=0.1). CONCLUSION: This analytical work contributed to the design of a quality score for surgery. However, the progress of the score should continue to take into account all the obstacles that were observed and to meet the high requirements of the actual patient safety issue.

[Adult onset nemaline myopathy revealed by respiratory insufficiency]. / Révélation d'une myopathie à bâtonnets par une insuffisance respiratoire de l'adulte.

INTRODUCTION: We report a case of nemaline myopathy revealed in adulthood by a respiratory insufficiency. CASE REPORT: A 26-year-old patient, without past history, was admitted with respiratory and right cardiac insufficiency which appeared in a few days. There was a severe restrictive lung impairment with nocturnal hypoventilation. Minor skeletal abnormalities and areflexia suggested a congenital myopathy. Muscle biopsy revealed a nemaline myopathy. CONCLUSION: Respiratory insufficiency is common in nemaline myopathy with infancy or childhood onset, but very rare in adults. It may be explained by multiple mechanisms.

[Transient central diabetes insipidus during a valproic acid poisoning]. / Diabète insipide central transitoire au cours d'une intoxication à l'acide valproïque.

A 39-year-old man was hospitalized after divalproate self-poisoning. He presented coma requiring tracheal intubation and mechanical ventilation at 11 hours and central diabetes insipidus. Serum valproic acid concentration was 590 mg/l at 30 hours. Progressive improvement occurred after hydratation and administration of vasopressin.