COVID-19 patients requiring mechanical ventilation are particularly at risk of developing ventilator-associated pneumonia (VAP). Risk factors and the prognostic impact of developing VAP during ...critical COVID-19 have not been fully documented.
Patients invasively ventilated for at least 48 h from the prospective multicentre COVID-ICU database were included in the analyses. Cause-specific Cox regression models were used to determine factors associated with the occurrence of VAP. Cox-regression multivariable models were used to determine VAP prognosis. Risk factors and the prognostic impact of early vs. late VAP, and Pseudomonas-related vs. non-Pseudomonas-related VAP were also determined.
3388 patients were analysed (63 55–70 years, 75.8% males). VAP occurred in 1523/3388 (45.5%) patients after 7 5–9 days of ventilation. Identified bacteria were mainly Enterobacteriaceae followed by Staphylococcus aureus and Pseudomonas aeruginosa. VAP risk factors were male gender (Hazard Ratio (HR) 1.26, 95% Confidence Interval 1.09–1.46), concomitant bacterial pneumonia at ICU admission (HR 1.36 1.10–1.67), PaO2/FiO2 ratio at intubation (HR 0.99 0.98–0.99 per 10 mmHg increase), neuromuscular-blocking agents (HR 0.89 0.76–0.998), and corticosteroids (HR 1.27 1.09–1.47). VAP was associated with 90-mortality (HR 1.34 1.16–1.55), predominantly due to late VAP (HR 1.51 1.26–1.81). The impact of Pseudomonas-related and non-Pseudomonas-related VAP on mortality was similar.
VAP affected almost half of mechanically ventilated COVID-19 patients. Several risk factors have been identified, among which modifiable risk factors deserve further investigation. VAP had a specific negative impact on 90-day mortality, particularly when it occurred between the end of the first week and the third week of ventilation.
Diets higher in plants are associated with lower risks of chronic diseases. However, animal foods, which are rich in protein, are also rich in some important minerals and vitamins. Using data from a ...representative survey in France (INCA3,
n
= 1,125), we used path analyses as a mediation-like approach to decipher the importance of plant and animal proteins in the relationship between the plant-based diet index (PDI) and diet quality. We used three types of diet quality scores, namely, nutrient security, positive nutrient adequacy, and long-term mortality risk of four diet-related diseases (i.e., coronary heart disease, stroke, type 2 diabetes, and colorectal cancer). We identified positive and negative mediations, i.e., changes in plant/animal protein intake that are associated with changes in PDI, and favor or limit the association with the diet quality score. The PDI was positively associated with the risk of long-term mortality but not significantly with nutrient adequacy or nutrient security. A positive mediation by plant protein was found for all diet quality scores (specific indirect effects (SIEs) ranging from 0.04 to 0.10 SD). Conversely, the association between PDI and nutrient adequacy (but not nutrient security) was negatively mediated by animal protein intake (SIE: −0.06 SD). In further detailed models, the association between PDI and diet quality was mainly positively mediated by protein foods from the fruit-vegetables-legumes group (0.01 SD for the nutrient security and 0.02 SD for the nutrient adequacy) and whole grains (0.02 SD for the nutrient adequacy). Our data suggest that the positive impact of plant-based diets on diet quality is largely driven by higher intakes of plant protein foods, especially from fruits-vegetables-legumes and whole grains. Conversely, lower animal protein intake tends to limit the positive impact of plant-based diets on overall positive nutrient adequacy but not security. Protein sources appear critical to healthy plant-based diets.
Burnout rates are estimated to be twice as high among healthcare professionals as in the general working population, and studies indicate rising incidence. The present study aimed to identify the ...contextual factors associated with self-reported burnout rates among French psychiatrists. A total of 860 French or French-speaking psychiatrists completed an online questionnaire when they registered for a major psychiatric conference. The Copenhagen Burnout Inventory, a validated scale that independently appraises personal, work- and patient-related dimensions, was used to assess the degree of perceived burnout. Respondents were divided into lower risk and higher risk groups. The latter contained the 25% of individuals who scored the highest on each of the three dimensions of the CBI scale. Univariate analysis showed that private practice was associated with lower levels of risk on the personal and work-related dimensions. Working for the public sector and long hours were both associated with a higher score on the work-related dimension. Interestingly, none of the variables we investigated, except from poor atmosphere at work, correlated with the patient-related dimension. Among public-sector psychiatrists, female gender, longer hours, and more consultations per week were associated with a higher score on the work-related dimension. Working four or more night shifts per month was significantly associated with a higher score of burnout risk on all three dimensions. Private- and public-sector practitioners who mainly treated patients with schizophrenia had a higher score of burnout risk. Multivariate analysis showed that a poor atmosphere at work, longer hours, and working four or more night shifts were significantly associated with higher score of burnout risk. A nonreassuring working environment and more stressors while treating patients each had a possibly negative impact. Although this study only examined the factors that distinguish between clinicians with the lowest
highest CBI burnout risk scores, it opens up important avenues for research and development of programs to reduce burnout risk within the French healthcare system.
Elderly individuals represent an increasing proportion of emergency department (ED) users. In the Greater Paris University Hospitals (APHP) direct-admission study, direct admission (DA) to an acute ...geriatric unit (AGU) was associated with a shorter hospital length of stay (LOS), lower post-acute care transfers, and lower risk of an ED return visit in the month following the AGU hospitalization compared with admission after an ED visit. Until now, no economic evaluation of DA has been available.
We aimed to evaluate the cost-effectiveness of DA to an AGU versus admission after an ED visit in elderly patients. This was conducted alongside the APHP direct-admission study which used electronic medical records and administrative claims data from the Greater Paris University Hospitals (APHP) Health Data Warehouse and involved 19 different AGUs. We included all patients ≥ 75 years old who were admitted to an AGU for more than 24 h between January 1, 2013 and December 31, 2018. The effectiveness criterion was the occurrence of ED return visit in the month following AGU hospitalization. We compared the costs of an AGU stay in the DA versus the ED visit group. The perspective was that of the payer. To characterise and summarize uncertainty, we used a non-parametric bootstrap resampling and constructed cost-effectiveness accessibility curves.
At baseline, mean costs per patient were €5113 and €5131 in the DA and ED visit groups, respectively. ED return visit rates were 3.3% (n = 81) in the DA group and 3.9% (n = 160) in the ED group (p = 0.21). After bootstrap, the incremental cost-effectiveness ratio was €-4249 (95%CI= -66,001; +45,547) per ED return visit averted. Acceptability curves showed that DA could be considered a cost-effective intervention at a threshold of €-2405 per ED return visit avoided.
The results of this cost-effectiveness analysis of DA to an AGU versus admission after an ED visit for elderly patients argues in favor of DA, which could help provide support for public decision making.
Background
Acute myocardial infarction (AMI) is one of the major cardiac complications in patients hospitalized in the intensive care unit (ICU) for non-cardiac disease. A better knowledge of ...ischemic and bleeding risks in these patients is needed to identify those most likely to benefit from specific cardiac management. We therefore assessed the incidence and predictors of a composite outcome of severe ischemic event (AMI recurrence, ischemic stroke), major bleeding, or all-cause death in this setting.
Methods
In this multicenter retrospective study, all consecutive adult patients admitted for non-cardiac disease to four French university hospital ICUs between January 2012 and December 2018 who had an AMI with obstructive coronary artery disease (OCAD) during the ICU stay were considered for inclusion. AMI with OCAD was defined as an elevated cardiac troponin value associated with at least one sign (clinical, electrocardiographic, or echocardiographic) suggestive of myocardial ischemia and presence of OCAD on coronary angiography. The primary endpoint was in-hospital occurrence of the composite outcome.
Results
Ninety-six patients median age 69 years, 22 women (23%), 59 with sepsis (61%), 35 with ST elevation (37%), median sequential organ failure assessment (SOFA) of 8 on the day of AMI were included. The median peak cardiac troponin value was 131 (IQR 44–303) times the upper reference limit. Dual antiplatelet, therapeutic anticoagulation, and early mechanical reperfusion therapies were administered in 61 (64%), 68 (71%), and 47 (49%) patients, respectively. The composite outcome occurred in 48 (50%) patients. Severe ischemic events occurred in 17 (18%) patients and major bleeding in 26 (27%) patients; 26 patients (27%) died in the hospital. AMI management was not significantly different in patients with and without the composite outcome. A history of arterial hypertension (HR 2.05, 95% CI 1.01–4.16) and high SOFA score at the time of AMI (HR 1.07, 95% CI 1.00–1.15) were independent risk factors for the composite outcome.
Conclusions
Patients who have an AMI with OCAD during an ICU stay for non-cardiac disease are at risk of a composite outcome of severe ischemia, major bleeding, and death. A history of arterial hypertension and high SOFA scores were independent hazards for poor prognosis.
Graphical Abstract
Information on epidural analgesia delivered to parturient women is frequently incomplete, making it difficult for expectant mothers to make an appropriate choice for their delivery. We assessed the ...impact of a multimodal information session on epidural analgesia delegated to anesthetic nurses on new-mothers' satisfaction.
We performed a prospective sequential study including parturient women who gave birth with epidural analgesia. During the first period, information on epidural analgesia was delivered by anesthetists during the scheduled anesthesia consultation, according to French standard-of-care. Then, a dedicated information session about epidural analgesia provided by anesthetic nurses was implemented. The primary endpoint was the satisfaction of women with the quality of information received. Main secondary endpoints were knowledge of women about epidural analgesia, anxiety before epidural catheter placement, and satisfaction with delivery.
259 and 298 women were included during the first and second periods respectively, among whom 178 and 188 were analyzed. Information on epidural analgesia delivered by anesthetic nurses was associated with improvement of new-mothers' satisfaction with information received (9 (8-10) vs. 10 (9-10) - p < 0.001). Moreover, information delivered by anesthetic nurses was associated with decreased anxiety before epidural catheter placement (4 (1-8) vs. 3 (1-6) - p = 0.006) and increased satisfaction with delivery (8 (7-10) vs. 9 (8-10) - p = 0.01). Women's knowledge on epidural analgesia was durably increased when information was delivered by anesthetic nurses compared to conventional information by anesthetists. After adjustment, the only variable associated with both new mothers' satisfaction with information and delivery was the information session taught by anesthetic nurses.
Information sessions on epidural analgesia delivered by anesthetic nurses was associated with improved satisfaction of women with their delivery. Such information sessions may be used in maternity wards to improve new-mothers' childbirth experience.
Identifying which patients with acute myocardial infarction (AMI) during sepsis are at risk of poor outcome is a clinical challenge.
To evaluate Global Registry of Acute Coronary Events (GRACE) and ...Thrombolysis In Myocardial Infarction (TIMI) risk scores to predict in-hospital mortality and severe ischaemic events in this setting.
In this single-centre retrospective study conducted from 2012 to 2016, all consecutive adults hospitalized in the intensive care unit for sepsis who had a concomitant AMI (within 72hours of admission) were enrolled. AMI was defined by an elevated cardiac troponin I value associated with at least one sign (clinical, electrocardiographic or echocardiographic) suggestive of myocardial ischaemia. The primary outcome was in-hospital mortality from any cause. Secondary outcomes were in-hospital occurrence of severe ischaemic events (cardiac arrest with resuscitation, ischaemic stroke and myocardial reinfarction) and major bleeding events.
Among 856 patients hospitalized for sepsis, 120 (14.5%) had a concomitant AMI (37.5% women; median age 65 years; median Sequential Organ Failure Assessment SOFA score 8). Severe ischaemic events occurred in 15 patients (12.5%), and 39 (33%) died in hospital. Neither the GRACE score (median 192, interquartile range 154–223) nor the TIMI score (median 3, interquartile range 2–4) was associated with occurrence of severe ischaemic events. Only the GRACE score was associated with in-hospital mortality (odds ratio 1.01, 95% confidence interval 1.00–1.02 per 1 point increase). Multivariable analysis identified previous aspirin use and SOFA score as independent factors associated with in-hospital mortality.
GRACE and TIMI scores did not predict in-hospital severe ischaemic events and mortality in patients with AMI during sepsis. Among individual components of both scores, previous aspirin use was associated with poor prognosis. However, because of lack of statistical power, we cannot formally rule out the usefulness of these scores in this setting.
Parmi les patients ayant un infarctus du myocarde (IDM) au décours d’un sepsis, identifier ceux à risque de mauvais pronostic est un défi clinique.
Notre objectif est d’évaluer les scores de risque GRACE et TIMI afin de prédire la mortalité intra-hospitalière et les évènements ischémiques sévères dans ce contexte.
Dans cette étude monocentrique rétrospective conduite de 2012 à 2016, tous les patients adultes hospitalisés en unité de soins intensifs pour un sepsis et présentant un IDM concomitant (dans les 72heures de l’admission) ont été consécutivement inclus. L’IDM était défini par une élévation de la troponine cardiaque I associée à la présence d’au moins un signe clinique, électrocardiographique ou échocardiographique suggérant une ischémie myocardique. Le critère de jugement principal était la mortalité intra-hospitalière toute cause. Les critères de jugement secondaires intra-hospitaliers étaient les évènements ischémiques sévères (arrêt cardiaque avec réanimation cardiopulmonaire, accident vasculaire cérébral ischémique, infarctus du myocarde récidivant) et les évènements hémorragiques sévères.
Parmi 856 patients hospitalisés pour sepsis, 120 patients (14,5 %) ont présenté un AMI concomitant (femme, 37.5 % ; âge médian, 65 ans, score SOFA médian 8). Un évènement ischémique sévère est survenu chez 15 patients (12.5 %) et 39 patients (33 %) sont décédés à l’hôpital. Ni le score GRACE (médiane 192, IQR 154–223), ni le score TIMI (médiane 3, IQR 2–4) n’étaient associés à la survenue d’un évènement ischémique sévère. Seul le score GRACE était significativement associé à la mortalité (OR 1.01, IC 95 % 1.00–1.02 par point). En analyse multivariée, la prise d’aspirine au long court et le score SOFA étaient indépendamment associés à la mortalité intra-hospitalière.
Ni le score GRACE, ni le score TIMI ne prédisent la survenue d’évènement ischémique sévère intra-hospitalier et la mortalité intra-hospitalière chez les patients présentant un IDM au cours d’un sepsis. Parmi les composants individuels des deux scores, la prise d’aspirine au long court était associée à un plus mauvais pronostic. Cependant, en raison du manque de puissance statistique, notre étude ne peut exclure formellement l’utilité de ces scores dans ce contexte.
To assess the diagnostic accuracy of existing clinical criteria and to develop prediction tools for iron deficiency in 2-year-old children.
In a national cross-sectional study conducted in primary ...care pediatricians' practices throughout France, 2-year-old children were consecutively included (2016-2017). Multivariable logistic regression modeling and bootstrapping were used to develop several clinical models to predict iron deficiency (serum ferritin <12 μg/L). These models used the best criteria and combinations among the American Academy of Pediatrics’ (AAP) criteria adapted to the European context (n = 10), then all potential predictors (n = 19). One model was then simplified into a simple prediction tool.
Among 568 included infants, 38 had iron deficiency (6.7%). In univariable analyses, no significant association with iron deficiency was observed for 8 of the 10 adapted AAP criteria. Three criteria (both parents born outside the European Union, low weight at 1 year old, and weaning to cow's milk without supplemental iron) were retained in the AAP model, which area under the receiver operating characteristic curve, sensitivity, and specificity were 0.62 (95% CI, 0.58-0.67), 30% (95% CI, 22%-39%), and 95% (95% CI, 92%-97%), respectively. Four criteria were retained in a newly derived simple prediction tool (≥1 criterion among the 3 previous plus duration of iron-rich formula consumption <12 months), which area under the receiver operating characteristic curve, sensitivity, and specificity were 0.72 (95% CI, 0.65-0.79), 63% (95% CI, 47%-80%), and 81% (95% CI, 70%-91%), respectively.
All prediction tools achieved acceptable diagnostic accuracy. The newly derived simple prediction tool offered potential ease of use.
ClinicalTrials.gov NCT02484274.
During the pandemic period, health care systems were substantially reorganized for managing COVID-19 cases. Corresponding consequences on persons with chronic diseases remain insufficiently ...documented. This observational cohort study investigated the direct and indirect impact of the pandemic period on the survival of kidney transplant recipients (KTR). Using the French National Health Data System, incident persons with end-stage kidney disease between 2015 and 2020, and who received a kidney transplant during this period were included and followed up from their transplantation date to December 31, 2021. The survival of KTR during the prepandemic and pandemic periods was investigated using Cox models with time-dependent covariates. There were 10 637 KTR included in the study, with 324 and 430 deaths observed during the prepandemic and pandemic periods, respectively. The adjusted risk of death during the pandemic period was similar to that observed during the prepandemic period (hazard ratio HR 95% confidence interval: 0.92 0.77-1.11), COVID-19–related hospitalization was associated with an increased risk of death (HR: 10.62 8.46-13.33), and a third vaccine dose was associated with a lower risk of death (HR: 0.42 0.30-0.57). The pandemic period was not associated with an indirect higher risk of death in KTR with no COVID-19–related hospitalization.
Background
Pentoxifylline possess antiinflammatory and rheological properties and has been tested in heart failure (HF).
Methods
A comprehensive search was performed from 1980 until July 2013 in ...PubMed, to identify randomized controlled trials evaluating pentoxifylline versus placebo in HF, to determine impact on mortality. Search strategy is as follows: “Pentoxifylline” AND “heart” AND “trial”. Study selection of six randomized controlled trials evaluating mortality as outcome. Then, we conducted a meta‐analysis of randomized controlled trials versus placebo in HF. Determination of Mantel–Haenszel fixed effect and random‐effect pooled odds ratios for all‐cause mortality and corresponding 95% confidence intervals.
Results
Data from a total of 221 patients with LVEF ≤40% from six randomized controlled trials were included in this analysis. Pentoxifylline 1200 mg per day was administered during 6 months, except in one study (administered during 1 month for severe acute HF). The use of pentoxifylline was not significantly associated with a reduction in mortality in HF in individual studies. The pooled data including 221 patients showed a nearly fourfold reduction in mortality (5.4% vs. 18.3%; OR 0.29; CI 0.12–0.74; P < 0.01) with homogenous results (I² 0%).
Conclusion
A meta‐analysis evaluating pentoxifylline versus placebo in HF suggested a significant nearly fourfold decrease in all‐cause mortality in the pentoxifylline group.
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