Why are people still dying of drug-susceptible TB in Paris in the 21st century?

BACKGROUND: Although the burden of TB is lower in France than in low-income countries, patients continue to die from TB in Paris. Our goal was to describe TB-related deaths and to identify associated risk factors.METHODS: We conducted a retrospective cohort study in two hospitals in Paris between 2013 and 2018. All patients with drug-susceptible TB were included and followed until end of treatment. The primary outcome was death. We performed univariate and multivariate analysis using Cox proportional hazard model.RESULTS: Of the 523 patients included, 362 were men (median age 37 years), of whom 24 patients died (4.5%). The final survival model concluded that age (HR 1.1 for each additional year), not living in one´s own accommodation (HR 5.9), being born in France (HR 8.0), being alcoholic (HR 4.2), having a history of cancer (HR 7.1) or meningeal or miliary TB (HR 8.2) were associated with a higher risk of death.CONCLUSION: The rate of TB-associated death is unacceptably high for a curable disease. To note, patients born in France were much more at risk of death than immigrants. We believe raising awareness among healthcare professionals is a potentially easy and efficient lever for improving care.

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.

[Term Prelabor Rupture of Membranes: CNGOF Guidelines for Clinical Practice - Short Text]. / Rupture des membranes à terme avant travail. Recommandations pour la pratique clinique du CNGOF ­ Texte court.

OBJECTIVE: To determine the management of patients with term prelabor rupture of membranes. METHODS: Synthesis of the literature from the PubMed and Cochrane databases and the recommendations of French and foreign societies and colleges. RESULTS: Term prelabor rupture of membranes is considered a physiological process up to 12hours of rupture (Professional consensus). In case of expectant management and with a low rate of antibiotic prophylaxis, home care compared to hospitalization could be associated with an increase in neonatal infections (LE3), especially in case of group B streptococcus colonization (LE3). Home care is therefore not recommended (Grade C). In the absence of spontaneous labor within 12hours of rupture, antibiotic prophylaxis could reduce the risk of maternal intrauterine infection but not of neonatal infection (LE3). Its use after 12hours of rupture in term prelabor rupture of the membranes is therefore recommended (Grade C). When antibiotic prophylaxis is indicated, intravenous beta-lactams are recommended (Grade C). Induction of labor with oxytocin (LE1), prostaglandin E2 (LE1) or misoprostol (LE1), is associated with shorter rupture of membranes to delivery intervals when compared to expectant management. Compared with expectant management, immediate induction of labor is not associated with lower rates of neonatal infection (LE1), even among women with a positive streptococcus B vaginal swab (LE2). Thus, expectant management can be offered without increasing the risk of neonatal infection (Grade B). Induction of labor is not associated with an increase or decrease in the cesarean delivery rate (LE2), whatever parity (LE2) or Bishop score at admission (LE3). Induction can thus be proposed without increasing the risk of cesarean delivery (Grade B). No induction method (oxytocin, dinoprostone, misoprostol or Foley® catheter) has demonstrated superiority over another, whether to reduce rate of intrauterine or neonatal infection, rate of cesarean delivery or to shorten rupture of membranes to delivery intervals regardless of Bishop's score and parity. CONCLUSION: Term prelabor rupture of membranes is a frequent event. A 12-hour delay without onset of spontaneous labor was chosen to differentiate a physiological condition from a potentially unsafe situation justifying an antibiotic prophylaxis. Expectant management or induction of labor can both be proposed, even in case of positive screening for streptococcus B, depending on the patient's wishes and maternity units' organization (Professional consensus).

Pharmacokinetics of dolutegravir in a premature neonate after HIV treatment intensification during pregnancy.

We describe the pharmacokinetics of dolutegravir (DTG) in a premature neonate after maternal intensification of an antiretroviral (ARV) regimen by adding DTG. During the last 2 weeks of pregnancy, the ARV was tenofovir-emtricitabine, atazanavir-ritonavir, and DTG (50 mg once daily). From the interaction between atazanavir and DTG via CYP3A4 and UGT1A1 and placental efflux transporter inhibition and considering the infant's probable enzymatic immaturity, the DTG elimination half-life was estimated to be 4-fold longer in neonates than in adults.

[Risk factors and perinatal consequences of short interpregnancy interval: a retrospective case-control study]. / Facteurs de risques et conséquences périnatales des grossesses rapprochées : étude cas-témoin rétrospective.

OBJECTIVES: To study the maternal risk factors and perinatal complications of a short interpregnancy interval. PATIENTS AND METHODS: Retrospective case-control study between 2007 and 2009, comparing a group with a short interpregnancy interval (less than 9 months, n=83), and a control group (interval between two pregnancies between 18 and 24 months, n=166). RESULTS: The main risk factor of short interpregnancy interval is to be unemployed (OR=3.2, P<0.001). There is a significant link between lack of prescription contraceptives in postpartum and a short interval between pregnancies (OR=3.4, P<0.001). We also found a higher rate of anemic women during pregnancy (OR=4.9, P=0.001) and postpartum (OR=2.1, P=0.02) in case of short interpregnancy interval. Short interpregnancy interval increases risk of small for gestational age (OR=2.4, P=0.05) and thermoregulation disorders (OR=3.1, P=0.02). CONCLUSION: A low socioeconomic level is a risk factor of short interpregnancy interval. Short interpregnancy interval is at risk of maternal iron deficiency and neonatal complications like low birth weight and hypothermia.

[Malaria among immigrants, experience of a Parisian hospital (2006-2010)]. / Paludisme chez les migrants, expérience d'un hôpital parisien (2006-2010).

In recent days immigrants represent the main risk group for imported malaria in northern countries. Most of them are migrants returning to their country of origin to visit friends and relatives (VFR). We retrospectively examined the main clinical, biological, and therapeutic data of all malaria cases in immigrants from 2006 to 2010 in Tenon hospital, Paris. The hospital is situated in a Paris district with an important African community. During the study period 239 imported malaria cases were observed in adults of which 199 were immigrants, 186 VFR, and 13 recently arrived. Most cases were from sub-Saharan Africa and Comoro islands. Chimioprophylaxis was not taken in 81.2% of VFR. It was inadequate in 43.7% and not taken correctly in 84.4%. Plasmodium falciparum was the most frequent species identified: 190/199 (95.5%). Severe P. falciparum malaria was observed in 25 cases (13.2%); two of them were recently arrived. One patient, African VFR, died. In this series two high-risk groups were represented: HIV-infected patients and pregnant women. Six of the HIV patients had severe malaria and all pregnant women had anemia. Our results are similar to those observed recently in other European countries. Mean age of VFR is increasing and the risk for severe P. falciparum malaria became identical to the one observed in non-immune travelers. Protection measures remain still insufficient in this population of travelers.

[Acute pancreatitis induced by major hypertriglyceridemia during pregnancy. A case report]. / Pancréatite aiguë secondaire à une hypertriglycéridémie majeure au cours de la grossesse. A propos d'un cas.

A parturient in the 37th week of gestation is referred to the obstetrical emergency ward for an acute abdominal pain with vomiting and fever. Few hours after her admission, a caesarean section is performed for acute fetal distress. It gave birth to a 3940 g healthy newborn. An abundant and milky peritoneal fluid is noted during the C-section related to a major hypertriglyceridemia (84,47 g/L) which induced an acute pancreatitis explaining the early symptoms. The patient is then hospitalized in surgical reanimation: heparin and a low fat diet led to a quick decrease of triglyceridemia and the healing of the acute pancreatitis. We review the most recent literature about acute pancreatitis during pregnancy, especially induced by hypertriglyceridemia, and the different management option: heparin, parenteral nutrition or plasmapheresis.

[Imported cases of dengue fever diagnosed in metropolitan France, from January 2001 to December 2006]. / Dengue d'importation diagnostiquée en France métropolitaine, janvier 2001-décembre 2006.

INTRODUCTION: Dengue fever is the main emerging vector-borne disease worldwide. It was estimated that 40% of the world population is at risk. A potential vector (Aedes albopictus) is present in four French departments of the southeast area of metropolitan France. METHOD: The authors tried to document the number of imported cases of dengue diagnosed from 2001 to 2006, inclusive, as well as their main features. RESULTS: Between 12 and 28 cases of imported dengue were diagnosed every month during that period (eight to 18 cases per month except for years 2001-2002 during which an important dengue epidemic was documented in the French West Indies). Nearly 40% of the cases were imported between June and September during which the vector is active in the metropolitan area. CONCLUSION: This data underlines the strong and close link between the endemic zones of the French territory (French West Indies and Guyana) and the risk of imported cases to metropolitan France. The identification of this "importation track" entails strengthening the system for detecting and managing imported dengue cases in metropolitan France when a dengue epidemic is detected in the French West Indies.

[Emerging viral infections in South East Asia and the Pacific region]. / Viroses émergentes en Asie du Sud-Est et dans le Pacifique.

The epidemiology of several viral diseases underwent profound changes in South-East Asia and Oceania over the past decades. This was due to several factors, including the geographical distribution of vectors and the viruses they transmit; increasing traveling and trade; increasing ecological and demographic pressure. We reviewed the current state of knowledge based on published sources and available epidemiological data. The review was limited to potentially emerging viruses in Southeast Asia and the Pacific reported in human cases. Dengue, Chikungunya, and Japanese Encephalitis viruses have recurred on a yearly basis with a steady increase in these regions. Ross River and Barmah viruses now appear regularly in Australia, in an increasing number of cases. Nipah virus strikes regularly with limited but deadly epidemics in Southeast Asia. Finally, infections by lyssaviruses, Kunjin, Murray Valley, or Zika viruses were also reviewed.

[Antenatal metastatic neuroblastoma: prognostic criteria. A case report]. / Le neuroblastome métastatique anténatal: critères pronostiques. A propos d'un cas.

Neuroblastoma, the most common malignant tumor in the neonatal period is metastatic in 25 to 50% of cases. While the prognosis of antenatal neuroblastoma is often considered as favorable, included in the most common metastatic stage (Stage IV S), it can lead to fetal or neonatal death. We report a case of a fetus with a stage IV neuroblastoma who died in utero. The most important prognostic factor is tumor stage, making sonographic detection of metastasis essential. Nevertheless, accurate staging remains difficult by sonography. When metastatic neuroblastoma is suspected, sonographic survey has to be reinforced, and if serious criteria such as massive hepatomegaly, placentomegally or hydrops appear, delivery must be considered.

[Intravenous beta-2-adrenergic agonists for tocolytic therapy in pre-eclampsia: two cases of acute pulmonary edema]. / Bêta 2-mimétiques intraveineux pour tocolyse au cours de la prééclampsie: deux cas d'oedème aigu du poumon.

Two cases of pulmonary oedema during beta 2-adrenergic agonist therapy in pre-eclampsia pregnant patients are reported. In our first case, the pulmonary oedema was exceptionally severe, because the patient (twins at 26 SA) had to be intubated and ventilated, but the caesarean section was performed only 6 weeks later. These two clinical observations underline the fact that B2 adrenergic agonist are not indicated for the treatment of preeclampsy. Furthermore they suggest that such patients should be rapidly admitted to intensive care units.

[Markers of infection and inflammation in the amniotic fluid: therapeutic contribution of amniocentesis]. / Marqueurs de l'infection et de l'inflammation dans le liquide amniotique: intérêt de l'amniocentèse dans la prise en charge.

A part of preterm labor with intact membranes seems to be related to amniotic infection or local inflammatory process. In these cases, amniotic fluid is collected by amniocentesis for bacteriological studies: amniotic cultures are positive in 10% and polymerase chain reaction (PCR) in 40-50%. Interleukin 6 (IL6) concentrations are elevated in cases with amniotic infection and in some cases with negative cultures. IL6 amniotic concentrations are predictive of premature delivery and neonatal morbidity. Matrix metalloproteinases (MMP) are endogenous enzymes implicated in membrane weakening. Amniotic concentrations of these enzymes seem to be predictive of premature delivery and neonatal prognosis. Furthermore, at the time of genetic amniocentesis, IL6 and MMP concentrations are markers for preterm delivery. In the second half of gestation, amniocentesis is a safe procedure complicated in less than 1% of cases, although specific evaluation in cases of premature labor is missing. Nevertheless, as long as there is no evidence of any benefit in this procedure, there is no indication for amniocentesis in premature labor with intact membranes in general practice.

Patent ductus arteriosus and cystic periventricular leucomalacia in preterm infants.

AIM: To test the association between early disturbances in hemodynamics induced by left-to-right shunting through the duct and cystic periventricular leucomalacia. PATIENTS: Forty-six preterm infants (27-32 wk) admitted to the neonatal intensive care unit with risk criteria. METHODS: Patent ductus arteriosus was evaluated on days 1 and 4, and was significant (sPDA) in cases of absent or reversed end diastolic flow in the subductal aorta. Resistance index was measured in the anterior cerebral artery and in the subductal aorta. MAIN OUTCOME: Diagnosis of cystic periventricular leucomalacia between day 10 and day 50. RESULTS: The 12 infants who developed cystic periventricular leucomalacia were compared with those who did not. On day 1, sPDA was more frequent (64% vs 26%; p = 0.03) in the cystic periventricular leucomalacia group, left ventricular output was higher (median = 341 vs 279 ml kg-1.min-1; p = 0.005), and rescue surfactant was more frequently used (83% vs 47%; p = 0.03). This latter association was confirmed by multivariate analysis. Resistance index in the anterior cerebral artery was increased in cases of significant patent ductus arteriosus (p < 0.01) and was correlated with resistance index in the subductal aorta. CONCLUSION: On day 1 in this selected population, sPDA has an effect on blood flow velocity waveform in cerebral arteries and is associated with an increase in the emergence of cystic periventricular leucomalacia. This association could be casual rather than causal.

[Management of premature rupture of the membranes at term: how long to delay? Results of a prospective multicentric study in 713 cases]. / Rupture prématurée des membranes à terme: quel délai d'expectative? Résults d'une étude prospective multicentrique, à propos de 713 cas.

OBJECTIVE: The aim of our study was to define he best delay for management of spontaneous rupture of the membranes at term. MATERIALS AND METHODS: We conducted a prospective multicentric study in western France defining 3 groups of expectancy (6, 12 and 24 hours) to assess obstetrical, neonatal and maternal outcomes. RESULTS: We included 713 patients. There was no significant difference in neonatal and maternal morbidity between the 3 groups. The rate of cesarean section was statistically higher in the 6-hour group (12%). There was no statistical difference between 12 and 24 hours but the rate was lower in the 12-hour group (5.5 versus 7.9%). CONCLUSION: Based on our findings and a review of the literature, we have decided that in cased of premature rupture of the membranes at term, a 12 hour delay is best. At most two prostaglandin maturations can be performed in unfavorable cervixes.

[Percutaneous umbilical blood sampling in pregnant women with thrombocytopenia. Apropos of 35 cases]. / Ponction de sang foetal au cours des thrombopénies de la femme enceinte. A propos de 35 cas.

OBJECTIVE: To determine the interest of percutaneous umbilical blood sampling in maternal thrombocytopenia. PATIENTS AND METHOD: We performed a retrospective study of 36 percutaneous umbilical samples in pregnant women with thrombocytopenia. We included patients with a platelet count less than 100,000/mm(3) or a previous diagnosis of idiopathic thrombocytopenic purpura. Patients were divided into two groups. Group A consisted of women whose thrombocytopenia was caused by idiopathic thrombocytopenic purpura. The other patients were included in the group B. Percutaneous umbilical blood samples were performed by direct ultrasound guidance under sterile conditions, after 37 weeks gestation. Cesarean section was indicated if the fetal platelet count was < or =50 000/mm(3), in other cases obstetric indications were followed. RESULTS: Percutaneous umbilical blood samples were performed at a mean age of 38.5 gestational weeks. Fetal blood sampling was successful in 34 of the 36 cases. There was no fetal complication. In group A, two fetuses had low cord-blood platelet counts (20,000 and 98,000 per cubic millimeter). There was no fetal thrombopenia in group B. Three cesarean sections were performed, in one case because of severe fetal thrombocytopenia and in 2 cases because of an unsuccessful percutaneous umbilical blood sampling (in both, neonatal platelet count was normal). There was no significant complication in infants. There was a significant correlation between fetal and neonatal platelet count. CONCLUSION: There is no maternal predictive factor for fetal thrombocytopenia. Percutaneous umbilical blood sampling is feasible and has a good diagnostic value. The overall risk of fetal loss is low. But there is no indication of percutaneous umbilical blood sampling in the management of thrombocytopenia in pregnancy because severity of thrombopenia is not directly related to the severity of maternal disease and there are no series large enough to assess the association between delivery method and intracranial hemorrhage in thrombocytopenic infants born of mothers with idiopathic thrombocytopenic purpura. More subjectively than on scientific arguments a percutaneous umbilical blood sampling could be performed for patients with idiopathic thrombocytopenia purpura and a past history of neonatal intracranial hemorrhage. A cesarean section could be done if the platelet count is less than 100 000/mm(3), no intracranial hemorrhage has been described above this level.