Context
The 30-day readmission rate after bariatric surgery is considered an important metric of the quality of hospital care. However, readmission rate beyond 30 days is rarely reported and does not ...provide any information about trajectories of care which would be of great interest for healthcare planning. The aim of this study was to analyze trajectories of care during the first year after bariatric surgery on a nationwide basis using data mining methods.
Method
This was a retrospective descriptive study on the trajectories of care within the first year after bariatric surgery. Data were extracted from a national administrative claims database (the PMSI database) and trajectories were defined as principal diagnosis of successive readmissions. Formal Concept Analysis was performed to find common concepts of trajectories of care.
Results
We included for analysis 198,389 bariatric procedures performed on 196,323 patients. Twelve main concepts were selected. About one third of patients (32.4%) were readmitted in the first year after surgery. Most common trajectories were as follows: regular follow-up (14.9%), cholelithiasis (2.2%), abdominal pain (1.9%), and abdominal sepsis (1.3%). Important differences were found in trajectories among different bariatric procedures: 1.8% of gastric banding patients had pregnancy-related events (delivery or medical abortion), while we observed a readmission rate for abdominal sepsis in 2.7% and 5.1% of patients operated of gastric bypass and sleeve gastrectomy respectively.
Conclusion
Administrative claim data can be analyzed through Formal Concept Analysis in order to classify trajectories of care. This approach permits to quantify expected postoperative complications and to identify unexpected events.
Granulomatosis with polyangiitis (Wegener's) (GPA) and microscopic polyangiitis (MPA) are subgroups of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) defined historically by ...clinical and histological features. GPA and MPA are heterogeneous entities with overlapping phenotypes. To identify novel subgroupings, cluster analysis was used to explore the phenotypic spectrum of AAV.
This study used a dataset of patients newly diagnosed as having GPA and MPA enrolled in five clinical trials. One cluster model included nine clinical baseline variables as input variables, and a second cluster model additionally included ANCA specificities. The clustering process involved multiple correspondence analyses followed by hierarchical ascendant cluster analysis. The clinical relevance of the generated clusters was analysed by their summary characteristics and outcomes.
The analyses involved data for 673 subjects: 396 (59%) with GPA and 277 (41%) with MPA. Both cluster models resulted in five partially redundant clusters of subjects, and the model including ANCA resulted in more pertinent separations. These clusters were named 'renal AAV with proteinase 3 (PR3)-ANCA' (40% of subjects), 'renal AAV without PR3-ANCA' (32%) and 'non-renal AAV' (12%), 'cardiovascular AAV' (9%) and 'gastrointestinal AAV' (7%). The five clusters had distinct death and relapse rates. On the basis of 4 variables, 651 subjects (97%) could be accurately allocated to 1 of the 5 classes.
This analysis suggests that AAV encompasses five classes associated with different outcomes. As compared with the traditional GPA-MPA separation, this classification system may better reflect the phenotypic spectrum of AAV.
Myotonic Dystrophy type 1 (DM1) is one of the most heterogeneous hereditary disease in terms of age of onset, clinical manifestations, and severity, challenging both medical management and clinical ...trials. The CTG expansion size is the main factor determining the age of onset although no factor can finely predict phenotype and prognosis. Differences between males and females have not been specifically reported. Our aim is to study gender impact on DM1 phenotype and severity.
We first performed cross-sectional analysis of main multiorgan clinical parameters in 1409 adult DM1 patients (>18 y) from the DM-Scope nationwide registry and observed different patterns in males and females. Then, we assessed gender impact on social and economic domains using the AFM-Téléthon DM1 survey (n = 970), and morbidity and mortality using the French National Health Service Database (n = 3301).
Men more frequently had (1) severe muscular disability with marked myotonia, muscle weakness, cardiac, and respiratory involvement; (2) developmental abnormalities with facial dysmorphism and cognitive impairment inferred from low educational levels and work in specialized environments; and (3) lonely life. Alternatively, women more frequently had cataracts, dysphagia, digestive tract dysfunction, incontinence, thyroid disorder and obesity. Most differences were out of proportion to those observed in the general population. Compared to women, males were more affected in their social and economic life. In addition, they were more frequently hospitalized for cardiac problems, and had a higher mortality rate.
Gender is a previously unrecognized factor influencing DM1 clinical profile and severity of the disease, with worse socio-economic consequences of the disease and higher morbidity and mortality in males. Gender should be considered in the design of both stratified medical management and clinical trials.
Background: Little is known about systemic, environmental, and periodontal risk factors of gingival recessions. This study identifies variables related to buccal gingival recessions in an adult ...French population; this study uses data collected in the First National Periodontal and Systemic Examination Survey.
Methods: This cross‐sectional survey includes 2,074 subjects (age range: 35 to 65 years) from a nationally representative sample obtained by a quota method stratified by age, gender, socioeconomic status, and geographic areas. The subjects had undergone a full‐mouth periodontal examination, assessment of missing teeth, laboratory tests, and questionnaires. In the present analysis, the buccal gingival recession status of each subject was the outcome of interest and was assessed by criteria based on the severity and extent of gingival recessions.
Results: A total of 84.6% of the sample had at least one gingival recession. A multivariate linear regression model with backward selection showed that age (P >0.001), gender (P = 0.003), plaque index (P <0.001), and tobacco consumption (P <0.001) were associated with the extent of gingival recession. In addition to these variables, the number of missing teeth (P <0.001) and the gingival bleeding index (P = 0.010) were also associated with the severity of gingival recession.
Conclusions: This study indicates that the risk factors for gingival recessions are similar to the traditional risk factors for periodontitis. However, the present model indicates that diabetes, increase of the body mass index, and alcohol intake are not associated with gingival recessions.
Pulse pressure is a stronger predictor of cardiovascular events than systolic or diastolic blood pressure in large cohorts of French and North American patients. However, its influence on stroke is ...controversial. Large-artery stiffness is the main determinant of pulse pressure. The influence of arterial stiffness on the occurrence of stroke has never been demonstrated. Our aim was to establish the relationship between aortic stiffness and stroke death in hypertensive patients.
We included, in a longitudinal study, 1715 essential hypertensive patients who had a measurement of arterial stiffness at entry (ie, between 1980 and 2001) and no overt cardiovascular disease or symptoms. Mean follow-up was 7.9 years. At entry, aortic stiffness was assessed from the carotid-femoral pulse wave velocity. A Cox proportional hazard regression model was used to estimate the relative risk (RR) of stroke and coronary deaths.
Mean+/-SD age at entry was 51+/-13 years. Twenty-five fatal strokes and 35 fatal coronary events occurred. Pulse wave velocity significantly predicted the occurrence of stroke death in the whole population. There was a RR increase of 1.72 (95% CI, 1.48 to 1.96; P<0.0001) for each SD increase in pulse wave velocity (4 m/s). The predictive value of pulse wave velocity remained significant (RR=1.39 95% CI, 1.08 to 1.72; P=0.02) after full adjustment for classic cardiovascular risk factors, including age, cholesterol, diabetes, smoking, mean blood pressure, and pulse pressure. In this population, pulse pressure significantly predicted stroke in univariate analysis, with a RR increase of 1.33 (95% CI, 1.16 to 1.51) for each 10 mm Hg of pulse pressure (P<0.0001) but not after adjustment for age (RR=1.19 95% CI, 0.96 to 1.47; P=0.10).
This study provides the first evidence, in a longitudinal study, that aortic stiffness is an independent predictor of fatal stroke in patients with essential hypertension.
To study the impact of high-dose therapy (HDT) with autologous stem-cell support in patients with symptomatic multiple myeloma (MM) between the ages of 55 and 65 years.
One hundred ninety patients ...between 55 and 65 years old who had newly diagnosed stage II or III MM were randomly assigned to receive either conventional chemotherapy (CCT; ie, monthly courses of a regimen of vincristine, melphalan, cyclophosphamide, and prednisone) or HDT and autologous blood stem-cell transplantation (using either melphalan alone 200 mg/m(2) intravenous IV or melphalan 140 mg/m(2) IV plus busulfan 16 mg/kg orally as pretransplantation cytoreduction).
Within a median follow-up of 120 months, median event-free survival (EFS) times were 25 and 19 months in the HDT and CCT groups, respectively. Median overall survival (OS) time was 47.8 months in the HDT group compared with 47.6 months in the CCT group. A trend to better EFS (P = .07) was observed in favor of HDT, whereas OS curves were not statistically different (P = .91). The period of time without symptoms, treatment, and treatment toxicity (TwiSTT) was significantly longer for the HDT patients than for the CCT patients (P = .03).
With a median follow-up time of approximately 10 years, this randomized trial confirmed a benefit of HDT in terms of EFS and TwiSTT but did not provide evidence for superiority of HDT over CCT in OS of patients aged 55 to 65 years with symptomatic newly diagnosed MM.
Following recent health scandals in France, the French parliament adopted law n°2011-2012 to regulate ties between physicians and the pharmaceutical industry. The law also requires pharmaceutical ...companies to publicize financial and other benefits given to medical students. In this context, we administered a survey to medical students in France, in an effort to identify priorities for future education regarding conflicts of interest (COI). This web-based survey encompassed knowledge about, training on, personal exposure to, and opinions on COI among preclinical and clinical students as well as residents. Two thousand one hundred and one (2,101) students participated. Although most students (64.6%) believed that they are able to define what a COI is, they failed to correctly identify several situations as COI (receiving a gift, being offered a meal, being invited to a conference). Most students reported feeling inadequately educated about COI (85.2%). Compared to other class levels, residents were more exposed to pharmaceutical sales representatives. This exposure is highly associated to receipt of gifts (OR 14.51, 95% CI 11.67-18.05). Medical students were aware of potential bias induced by COI with respect to drug prescriptions and research, but felt personally immune towards COI. In our survey, personal research performed by students was more likely to be associated with perception of potential bias on prescription for self (but not for others) than attending a lecture on COI. Promulgating laws that regulate ties between physicians/students and the pharmaceutical industry is a mandatory first step. However, complementary strategies should be implemented within medical schools, in particular, specific training about COI in early medical education.
Purpose
We previously showed that external cooling decreases day 14 mortality in febrile septic shock. Because cooling may participate in heart rate control, we studied the respective impact of heart ...rate and temperature lowering on mortality.
Methods
Post hoc analysis of the Sepsiscool randomized controlled trial database (NCT00527007). Cooling was applied to maintain normothermia (36.5–37 °C) during 48 h. We assessed the time spent below different thresholds of temperature and heart rate on day 14 mortality. The best threshold was selected by AUC-ROC and tested as a potential mediator of mortality reduction. Mediation analysis was adjusted for severity and treatments influencing temperature and heart rate evolution. Sensitivity analysis was done using only patients with appropriate antimicrobial therapy.
Results
A total of 197/200 patients with adequate heart rate and temperature monitoring were analyzed. The best threshold differentiating survivors and nonsurvivors was 38.4 °C for temperature and 95 b/min for heart rate. During the 48 h of intervention, cooling significantly increased the time spent with a temperature below 38.4 °C,
p
= 0.001, and with a heart rate below 95 b/min,
p
< 0.01. The longer was the time spent with a temperature below 38.4 °C, the lower was the mortality adjOR 0.17 (0.06–0.49),
p
= 0.001. The time spent with a heart rate below 95 b/min was similar in survivors and nonsurvivors adjOR 0.68 (0.27–1.72),
p
= 0.42. Mediation analysis showed that the time spent with a temperature below 38.4 °C was a significant mediator of mortality.
Conclusion
The time spent with a temperature below 38.4 °C was independently associated with patient’s outcome and explained 73 % of the effect of the randomization on the day 14 mortality. Heart rate lowering was not a mediator of mortality.
Cord blood is an important source of stem cells. However, nearly 90% of public cord blood banks have declared that they are struggling to maintain their financial sustainability and avoid bankruptcy. ...The objective of this study is to evaluate how characteristics of cord blood units influence their utilization, then use this information to model the economic viability and therapeutic value of different banking strategies.
Retrospective analysis of cord blood data registered between January 1st, 2009 and December 31st, 2011 in Bone Marrow Donor Worldwide. Data were collected from four public banks in France, Germany and the USA. Samples were eligible for inclusion in the analysis if data on cord blood and maternal HLA typing and biological characteristics after processing were available (total nucleated and CD34+ cell counts). 9,396 banked cord blood units were analyzed, of which 5,815 were Caucasian in origin. A multivariate logistic regression model assessed the influence of three parameters on the CBU utilization rate: ethnic background, total nucleated and CD34+ cell counts. From this model, we elaborated a Utilization Score reflecting the probability of transplantation for each cord blood unit. We stratified three Utilization Score thresholds representing four different banking strategies, from the least selective (scenario A) to the most selective (scenario D). We measured the cost-effectiveness ratio for each strategy by comparing performance in terms of number of transplanted cord blood units and level of financial deficit.
When comparing inputs and outputs over three years, Scenario A represented the most extreme case as it delivered the highest therapeutic value for patients (284 CBUs transplanted) along with the highest financial deficit (USD 5.89 million). We found that scenario C resulted in 219 CBUs transplanted with a limited deficit (USD 0.98 million) that charities and public health could realistically finance over the long term. We also found that using a pre-freezing level of 18 x 10(8) TNC would be the most cost-effective strategy for a public bank.
Our study shows that a swift transition from strategy A to C can play a vital role in preventing public cord blood banks worldwide from collapsing.
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