Amputation-free survival in the long-term follow-up and gender-related characteristics in patients revascularized for critical limb ischemia

OBJECTIVE

Patients with Critical Limb Ischemia (CLI) present a high risk of cardiovascular events and death. Revascularization is the cornerstone of therapy to relieve ischemic pain and prevent limb loss. Literature data suggest that women tend to present with worse outcomes after revascularization. The aim of the present study is to determine amputation-free survival in a long-term follow-up in women and men following endovascular revascularization procedure for CLI.

METHODS

From November 2013 to December 2020, 357 consecutive patients were retrospectively included. Clinical and biological parameters were recorded at baseline before endovascular revascularization. During follow-up until February 2023, overall survival and amputation-free survival (freedom from major amputation) were analysed using the Kaplan-Meier method. Univariate and multivariate analyses were performed to study the parameters associated with amputation-free survival. A P<0.05 was considered as statistically significant.

RESULTS

A total of 357 consecutive patients were included, 189 men and 168 women with CLI, with a mean age of 78.6±12 years. Treated hypertension (79%), diabetes mellitus (48%), coronary artery disease (39%) and protein malnutrition (61%) were the most prevalent comorbidities. Women were older than men with a mean age of 82.4±11.4 years (versus 75.4±11 years in men) and presented more frequently with protein malnutrition (70% of women). Prevalence of diabetes, tobacco use and history of coronary heart disease were significantly higher in men. During the 10-year follow-up period, 241 patients had died (68%) and 38 (11%) underwent major amputation, of whom 22 patients were still alive on February 2023. Median survival was 35.5 months [IQR: 29.5; 43] in the overall population, 38.5 [32; 50.4] months in women and 33.5 months [24.7; 43.5] in men. No gender-related differences were noted according to peri-procedural complications, survival probability and amputation-free survival. In multivariate analysis for amputation-free survival, age, previous coronary heart disease, C-reactive protein level, left ventricular ejection fraction (LVEF)<60% and albumin level<35g/L were correlated with poor outcome. In particular, protein malnutrition, as a treatable risk factor, appears significantly correlated with poor outcome in both men and women (HR=2.50 [1.16;5.38], P=0.0196 in men; HR=1.77 [1.00;3.13], P=0.049 in women).

CONCLUSION

The present results highlight that mortality in patients after endovascular revascularization remains high with a mortality rate of 28% at 1 year, 40% at 2 years and 51% at 3 years. Women represented a distinct population, almost 10-year older than their male counterparts, with more prevalent protein malnutrition. However, no gender-related difference was noted according to amputation-free survival on the long-term follow-up. Associated risk factors are mainly age, a history of coronary heart disease, pre-procedural inflammatory syndrome and protein malnutrition. Correction of malnutrition could have the potential to improve functional and general long-term prognosis in patients with CLI together with optimal medical and interventional management.

Peri-procedural complications following endovascular revascularization for critical limb ischemia

OBJECTIVE

Revascularization procedures are considered the cornerstone of therapy in patients with critical limb ischemia (CLI) and multiple procedures are often required to attain limb salvage. The aim of the present study is to determine the prevalence of peri-procedural complications after endovascular procedure, and to determine the clinical and biological characteristics of patients associated to the risk of peri-procedural complications.

METHODS

From November 2013 to May 2021, 324 consecutive patients were retrospectively included, of whom 99 underwent more than one revascularization procedure for contralateral CLI or clinical recurrence of CLI. A total of 532 revascularizations were performed. Clinical and biological parameters were recorded at baseline before endovascular revascularization. The occurrence of a peri-procedural complication (local complications, fatal and non-fatal major bleeding or cardiovascular events) was recorded up to 30days after revascularization. Univariate and multivariate analyses were performed to study the parameters associated with per-procedural complications. A P<0.05 was considered as statistically significant.

RESULTS

A total of 324 consecutive patients were included, 177 men and 147 women with CLI, with a mean age of 77.6±11.9years. Most of these patients had cardiovascular comorbidities (41% with a history of coronary heart disease, 78% treated hypertensive patients, 49% diabetic patients). Peri-procedural mortality occurred in 13 patients (4%) and 9 patients (2.8%) experienced major amputation at one-month following revascularization. Among the 532 revascularization procedures, 99 major bleeding events (22.8% of the cohort population) and 31 cardiovascular events (8.6% of the cohort population), were recorded in the peri-procedural period. Cardiovascular events were associated with peri-procedural mortality. Complications at the puncture site occurred during 38 of the 532 procedures (10.2% of the cohort population). Compared with patients undergoing a single revascularization procedure, patients with multiple procedures presented a higher risk of major bleeding events (48.5% vs. 11.6%, P<0.0001) and access site complications (20.2% vs. 5.78%, P<0.0001). In multivariate analysis, pulse pressure <60mmHg and hemoglobin level <10g/dl were correlated with the occurrence of major bleeding events; left ventricular ejection fraction<60% and the absence of statin treatment were correlated with the occurrence of cardiovascular complications; a high chronological rank of revascularization was correlated with the occurrence of local complication. Finally, age and gender were not associated with the occurrence of peri-procedural complication.

CONCLUSION

The present results highlight that multiple revascularization procedures for limb salvage are required in almost one third of the population with critical limb ischemia and were associated with the risk of major bleeding events and access site complications. The most frequent complications of peripheral vascular interventions were major bleeding events. Adverse cardiovascular events were related with peri-procedural mortality. Anemia, blood pressure, left ventricular ejection fraction and statin treatment are important parameters to consider for peri-procedural outcomes, independently of age, gender and the chronological rank of revascularization procedure.

Factors associated with psychological symptoms in hospital workers of a French hospital during the COVID-19 pandemic: Lessons from the first wave

Purpose

The COVID-19 pandemic has put hospital workers around the world in an unprecedented and difficult situation, possibly leading to emotional difficulties and mental health problems. We aimed to analyze psychological symptoms of the hospital employees of the Paris Saint-Joseph Hospital Group a few months after the 1st wave of the pandemic.

Participants and methods

From July 15 to October 1, 2020, a cross-sectional survey was conducted among hospital workers in the two locations of our hospital group using the Hospital Anxiety and Depression Scale (HADS) and Post-Traumatic Stress Disorder (PTSD) Checklist (PCL) to measure anxiety, depression, and PTSD symptoms. Factors independently associated with these symptoms were identified.

Results

In total, 780 participants (47% caregivers, 18% health administrative workers, 16% physicians, and 19% other professionals) completed the survey. Significant symptoms of anxiety, depression, and PTSD were reported by 41%, 21%, and 14% of the participants, respectively. Hierarchical regression analysis showed a higher risk of having psychological symptoms among those (1) who were infected by SARS-CoV-2 or had colleagues or relatives infected by the virus, (2) who retrospectively reported to have had an anxious experience during the first wave, and (3) with a previous history of burnout or depression. In contrast, job satisfaction appeared to be a protective factor. Overall, hospital workers showed the statistically same levels of anxiety, depression, and PTSD symptoms, regardless of their profession and whether they had worked in units with COVID-19 patients or not.

Conclusions

Our cross-sectional survey of 780 hospital workers shows that after the first wave, hospital employees had a significant burden of mental health symptoms. Specific preventive measures to promote mental well-being among hospital workers exposed to COVID-19 need to be implemented, first among particularly vulnerable staff, and then, for all hospital staff for whom anxiety is detected early, and not only those who were directly exposed to infected patients.

Patients with atherosclerotic peripheral arterial disease have a high risk of lung cancer: Systematic review and meta-analysis of literature

PURPOSE

Lung cancer and atherosclerosis share common risk factors. Literature data suggest that the prevalence of lung malignancy in patients with peripheral arterial disease (PAD) is higher than in the general population. Our goal was to determine, through a systematic literature review, the prevalence of lung cancer in patients with PAD.

METHODS

We consulted available publications in the Cochrane library, MEDLINE, PUBMED, EMBASE, and ClinicalTrials.gov. We included all articles, written in English or French, published between 1990 and 2020 reporting the prevalence of lung cancer in patients with PAD (atherosclerotic aortic aneurysm or peripheral occlusive diseases). Patients with coronary artery disease, cardiac valvulopathy or carotid stenosis were not included. We did not include case reports. We performed a critical analysis of each article. Data were collected from two independent readers. A fixed effect model meta-analysis allowed to estimate a summary prevalence rate.

RESULTS

We identified 303 articles, and selected 19 articles according to selection criteria. A total of 16849 patients were included (mean age 68.3 years, 75.1% of males). Aortic aneurysms were found in 29% of patients and atherosclerotic occlusive disease in 66% of patients. Lung cancer was identified in 538 patients, representing a prevalence of 3%.

DISCUSSION

Lung cancer is found in 3% of patients with atherosclerotic PAD. This prevalence is higher than that found in lung cancer screening programs performed in the general population of smokers and former smokers. These patients should be screened for lung cancer. Their selection may dramatically increase the benefit of lung cancer screening.

Influence of clinical suspicion on CT accuracy of acute mesenteric ischemia: Retrospective study of 362 patients

PURPOSE

Acute mesenteric ischemia (AMI) may be underdiagnosed when not clinically suspected before CT is performed. We assessed the influence of a clinical suspicion of AMI on the CT accuracy.

METHOD

This retrospective single-centre study included patients who underwent CT in 2014-2019 and had clinically suspected AMI and/or confirmed AMI. CT protocols were adapted based on each patient's presentation and on findings from unenhanced images. The CT protocol was considered optimal for AMI when it included arterial and portal venous phases. CT protocols, accuracy of reports, and outcomes were compared between the groups with and without suspected AMI before CT.

RESULTS

Of the 375 events, 337 (90 %) were suspected AMI and 66 (18 %) were AMI, including 28 (42 %) with and 38 without suspected AMI. These two groups did not differ significantly regarding the medical history, clinical presentation, or laboratory tests. The CT protocol was more often optimal for AMI in the group with suspected AMI (26/28 [93 %] vs. 28/38 [74 %], p = 0.046). Diagnostic accuracy was not different between groups with and without suspected AMI (26/28 [93 %] vs. 34/38 [90 %], p = 1.00). However, it was lower in the group without suspicion of AMI when the CT protocol was not optimal for AMI (27/28 [96 %] vs 7/10 [70 %], p = 0.048).

CONCLUSIONS

The negative influence of not clinically suspecting AMI can be mitigated by using a tailored CT protocol.

Secondary bleeding following proctological surgery: Rare but potentially severe

PURPOSE

Haemorrhage following proctological surgery is one of the complications with the greatest potential for severity. The aim of this work was to assess the frequency and risk factors of haemorrhage requiring hospitalization during 30-days postoperatively.

METHODS

A retrospective cohort review of all surgeries performed in a Parisian department of medico-surgical proctology between January 2016 and June 2018 was performed. Demographic and surgical data were collected for patients who were hospitalized for postoperative haemorrhage. Their analysis was conducted as a single analysis followed by multivariate analysis.

RESULTS

A total of 7533 surgeries were performed on 6727 patients. The mean patient age was 42.6 (±14.3) years and 67.2% were males. Postoperative haemorrhage occurred in 111 patients (1.5%) with a total of 123 haemorrhagic episodes (12 relapses) within a mean of 6 (±5.5) days. In therapeutic terms, 28.5% of haemorrhages required transfusion, 37.4% required haemostasis in the operating theatre and 14.6% required haemostasis under local anaesthesia. Using multivariate analysis, haemorrhage was more frequent after haemorrhoid surgery and in the case of anticoagulant treatment, particularly direct oral anticoagulants, and if the ASA score was equal to 3. Active smoking was associated with a decreased risk of haemorrhage.

CONCLUSION

Haemorrhage requiring hospitalization occurred in 1.5% of cases following proctological surgery, 52.8% were severe and recurred in 10.8% of cases. The study also specified certain risk factors for haemorrhage and demonstrated the protective effect of active smoking.

Clinic Versus Ambulatory Blood Pressure in Resistant Hypertension: Impact of Antihypertensive Medication Nonadherence

Clinic-ambulatory blood pressure (BP) difference is influenced by patients- and device-related factors and inadequate clinic-BP measurement. We investigated whether nonadherence to antihypertensive medications may also influence this difference in a post hoc analysis of the DENERHTN trial (Renal Denervation for Hypertension). We pooled the data of 77 out of 106 evaluable patients with apparent resistant hypertension who received a standardized antihypertensive treatment and had both ambulatory BP and drug-screening results available at baseline after 1 month of standardized triple therapy and at 6 months on a median of 5 antihypertensive drugs. After drug assay samplings on study visits, patients took their antihypertensive treatment under supervision immediately after the start of the ambulatory BP recording, and supine clinic BP was measured 24 hours post-dosing; both allowed to calculate the clinic minus daytime ambulatory systolic BP (SBP) difference (clinic-SBP–day-SBP). A total of 29 (37.7%) were found nonadherent to medications at baseline and 38 (49.4%) at 6 months. At baseline, the mean clinic-SBP–day-SBP difference in the nonadherent group was 12.7 mm Hg (95% CI, 7.8–17.7 mm Hg, P <0.001). In contrast, clinic SBP was almost identical to day-SBP in the adherent group (clinic-SBP–day-SBP difference, 0.1 mm Hg; 95% CI, −3.3 to 3.5 mm Hg; P =0.947). Similar observations were made at 6 months. Using receiver operating characteristics curves, we found that a 6 mm Hg cutoff of clinic-SBP–day-SBP difference had 67% sensitivity and 69% specificity to predict nonadherence to the triple therapy at baseline. In conclusion, a large clinic-SBP–day-SBP difference may help discriminating between adherence and nonadherence to treatment in patients with resistant hypertension.

Clinical Trial Registration—

URL: https://www.clinicaltrials.gov . Unique identifier: NCT01570777.

Decision Support Systems from the Standpoint of Knowledge Representation

Relationships between decision-support systems and knowledge representation are examined from three different points of view: the characteristics of medical decisions that might influence the selection of appropriate knowledge representations, – the extent to which different knowledge representations can support efficient medical decisions and, – the validation of knowledge hypotheses through the practice of decision support systems. A three-level model of knowledge representation is proposed that includes a contextual, a conceptual and a computational level. Taking into consideration the context that leads to the selection of a given representation raises the issue of multiexpertise and multirepresentation modeling. Implementation of decision support systems as sets of cooperative agents and integration in the health information systems are considered.

Identification of Patients at High Cardiovascular Risk: a Critical Appraisal of Applicability of Statistical Risk Prediction Models

Assessment of cardiovascular risk is widely proposed as a basis for taking management decisions about patients presenting with hypertension or hypercholesterolemia. Our aim was to critically assess the use of risk equations derived from epidemiological studies for the purpose of identifying high-risk patients.

Risk equations were retrieved from the MEDLINE database and then applied to a data set of 118 patients. This data set was an evaluation study of the clinical value of the World Health Organization 1993 hypertension guidelines for the decision to treat mild hypertensive patients. We calculated agreement: 1) between equations and 2) between equations and the decision to treat taken by the physician.

Most models were not applicable to our population, mainly because the original population had a narrow age range or comprised only males. Between-model agreement was better for the lower and upper risk quintiles than for the three other risk quintiles (0.58, 0.33, 0.34, 0.45, 0.70, from the lower to the upper risk quintile). When using an arbitrary threshold for defining high-risk patients (i.e. >2% per year), we observed a huge variation of the proportion of patients classified at high risk (from 0 to 17%). There was a poor agreement between risk models and the decision to treat taken by the physician. These results suggest that risk-based guidelines should be validated before their diffusion.

Auditory and visual 3D virtual reality therapy as a new treatment for chronic subjective tinnitus: Results of a randomized controlled trial

BACKGROUND

Subjective tinnitus (ST) is a frequent audiologic condition that still requires effective treatment. This study aimed at evaluating two therapeutic approaches: Virtual Reality (VR) immersion in auditory and visual 3D environments and Cognitive Behaviour Therapy (CBT).

METHODS

This open, randomized and therapeutic equivalence trial used bilateral testing of VR versus CBT. Adult patients displaying unilateral or predominantly unilateral ST, and fulfilling inclusion criteria were included after giving their written informed consent. We measured the different therapeutic effect by comparing the mean scores of validated questionnaires and visual analog scales, pre and post protocol. Equivalence was established if both strategies did not differ for more than a predetermined limit. We used univariate and multivariate analysis adjusted on baseline values to assess treatment efficacy. In addition of this trial, purely exploratory comparison to a waiting list group (WL) was provided.

RESULTS

Between August, 2009 and November, 2011, 148 of 162 screened patients were enrolled (VR n = 61, CBT n = 58, WL n = 29). These groups did not differ at baseline for demographic data. Three month after the end of the treatment, we didn't find any difference between VR and CBT groups either for tinnitus severity (p = 0.99) or tinnitus handicap (p = 0.36).

CONCLUSION

VR appears to be at least as effective as CBT in unilateral ST patients.

French Multicenter Evaluation of the Appropriateness of Admission to the Emergency Department of the Over-80s

BACKGROUND

Persons over 80 represents 40% of patients in French emergency services. We assessed the appropriateness of these admissions and sought to identify risk factors for inappropriate hospital stays.

METHODS

The appropriateness of admission was assessed in a prospective, cross-sectional, multicenter study in eight hospitals in France by means of the Appropriateness Evaluation Protocol (French version, AEPf) during two non-consecutive periods of four weeks in 2010. We analyzed admission of patients aged 80 and over who were admitted to the hospital after a stay in the emergency department of the same hospital. Demographics and morbidity factors were recorded as were administrative hospitalization data to identify risk factors associated with inappropriate admissions. We also evaluated the economic impact of inappropriate admissions. For cost analysis, all variables were obtained from anonymized hospital reports of a diagnosis-related group system used for funding of the hospitals by health insurance.

RESULTS

During two different periods, 1577 patients were included. 139 (8.8%) hospital admissions were inappropriate according to explicit criteria of the AEPf, but 18 of these (1.1%) were in fact considered appropriate by the physician responsible for the admission, leading to 121 (7.7%) inappropriate admissions. Multivariate logistic regression showed that patients with heart disease were less often subject to inappropriate admission (odds ratio OR= 0.36 [0.23; 0.56], p < 0.001), as also were patients who usually lived in a nursing home (OR = 0.53 [0.30; 0.87], p = 0.018) and patients with higher Acute Physiology Scores (OR = 0.97 [0.95; 0.99], p < 0.001). Inappropriate admission increased when patients had a syndrome as the main diagnosis (OR = 1.81 [1.81; 2.83], p = 0.010). By contrast, cognitive functions, gait and balance disturbance or falls, behavioral disorders and method of transport to the emergency department did not change the probability of inappropriateness. The median cost of the hospital stay of an older patient was 3 606.5 [2 498.1; 4 994.2] euros for inappropriate admissions.

CONCLUSION

Inappropriate emergency admissions of older patients were infrequent. None of the geriatric syndromes were linked with the phenomenon and principle causes were severity of illness, mention of a cardiac disease, unclear pattern of consultation and institutionalized way of life.

Assessment of five screening strategies for optimal detection of carriers of third-generation cephalosporin-resistant Enterobacteriaceae in intensive care units using daily sampling

There is no consensus on optimal screening procedures for multidrug-resistant Enterobacteriaceae (MDRE) in intensive care units (ICUs). Therefore, we assessed five strategies for the detection of extended-spectrum beta-lactamase (ESBL) and high-level expressed AmpC cephalosporinase (HL-CASE) producers. During a 3-month period, a rectal screening swab sample was collected daily from every ICU patient, from the first 24 h to the last day of ICU stay. Samples were plated on MDRE-selective media. Bacteria were identified using MALDI-TOF mass spectrometry and antibiograms were performed using disk diffusion. MDREs were isolated from 682/2348 (29.0%) screening samples collected from 93/269 (34.6%) patients. Incidences of patients with ESBL and HL-CASE producers were 17.8 and 19.3 per 100 admissions, respectively. In 48/93 patients, MDRE carriage was intermittent. Compared with systematic screening at admission, systematic screening at discharge did not significantly increase the rate of MDRE detection among the 93 patients (62% vs. 70%). In contrast, screening at admission and discharge, screening at admission and weekly thereafter, and screening at admission and weekly thereafter and at discharge significantly increased MDRE detection (77%, p 0.02; 76%, p 0.01; 86%, p<0.001, respectively). The difference in MDRE detection between these strategies relies essentially on the levels of detection of patients with HL-CASE producers. The most reasonable strategy would be to collect two samples, one at admission and one at discharge, which would detect 87.5% of the ESBL strains, 67.3% of the HL-CASE strains and 77.4% of all MDRE strains. This study should facilitate decision-making concerning the most suitable screening policy for MDRE detection in a given ICU setting.

[Tolerance and efficacy of preoperative radiation therapy for elderly patients treated for rectal cancer]

PURPOSE

To retrospectively assess the impact of age on tolerance and oncologic outcomes treated by neoadjuvant treatment for patients of 70 years old or above with locally advanced rectal cancer.

PATIENTS AND METHODS

Ninety-one consecutive patients were divided into three groups: group 1 from 70 to 75 years (n=31); group 2: 76 to 79 years (n=31) and group 3, patients aged 80 years or above (n=29). Radiation therapy was delivered according two schemes: 25Gy in five fractions (short scheme) or 45 to 50Gy with a classical fractionation (long scheme). Long scheme patients received a concomitant chemotherapy with 5-fluoro-uracile alone or associated with oxaliplatin.

RESULTS

The three groups were comparable for performance status, Charlson's score and T staging. Long scheme radiation therapy and chemotherapy were performed in 77.5, 74.5 and 48.3% of patients (P=0.03) and 77.4, 71 and 41.4% (P=0.006) in the groups 1, 2 and 3, respectively. All patients treated with the short scheme irradiation received the treatment without any acute toxicity. In the long scheme group, 65% of patients received the treatment on time and grade 3 or above toxicity was observed in 12% of patients who did not receive oxaliplatin and in 48% of patients who received oxaliplatin. The overall survival rate at 3 and 5 years was 66.9% and 60.8% in the group 1, 90.5% and 75.9% in the group 2 and 80.5% and 73.8% in the group 3 (P=0.15).

CONCLUSION

Neoadjuvant treatment is feasible with encouraging survival rates for patients aged 70 years and older. Short scheme radiation therapy seems to be an interesting option in this population.

Risk factors and clinical outcome of unsuspected pulmonary embolism in cancer patients: a case-control study

BACKGROUND

Little is known about the risk factors and outcome of unsuspected pulmonary embolism (UPE) in cancer patients.

OBJECTIVES

To assess the risk factors and outcome of UPE in cancer patients.

METHODS

The charts of 66 patients diagnosed with UPE were reviewed. Two control groups were selected: 132 cancer patients without pulmonary embolism (PE) and 65 cancer patients with clinically suspected PE. Variables associated with UPE were identified by multivariable analysis. Six-month survival and recurrent venous thromboembolism were compared by use of Cox proportional analysis.

RESULTS

Twenty-seven (40.9%) patients with UPE had symptoms suggesting PE. Adenocarcinoma (odds ratio [OR] 4.45; 95% confidence interval [CI] 1.98-9.97), advanced age (OR 1.18; 95% CI 1.02-1.38), recent chemotherapy (OR 4.62; 95% CI 2.26-9.44), performance status > 2 (OR 7.31; 95% CI 1.90-28.15) and previous venous thromboembolism (OR 4.47; 95% CI 1.16-17.13) were associated with UPE. When adjusted for tumor stage and performance status, 6-month mortality did not differ between patients with UPE and patients without PE (hazard ratio 1.40; 95% CI 0.53-3.66; P = 0.50). Patients with UPE were more likely to have central venous catheters and chemotherapy and less likely to have proximal clots than patients with clinically suspected PE. Recurrent venous thromboembolism occurred in 6.1% and 7.7% of patients with UPE and symptomatic PE, respectively.

CONCLUSION

UPE is not associated with an increased risk of death. Patients with clinically suspected PE and those with UPE have similar risks of recurrent venous thromboembolism.

[Role of French hospital claims databases from care units in epidemiological studies: the example of the "Cohorte Enfant Scanner" study]

BACKGROUND

The "Cohorte Enfant Scanner", a study designed to investigate the risk of radiation-induced cancer after childhood exposure to CT (computed tomography) examinations, used clinical information contained in the "programme de médicalisation des systèmes d'information" (PMSI) database, the French hospital activities national program based upon diagnosis related groups (DRG). However, the quality and adequacy of the data for the specific needs of the study should be verified. The aim of our work was to estimate the percentage of the cohort's children identified in the PMSI database and to develop an algorithm to individualize the children with a cancer or a disease at risk of cancer from medical diagnoses provided by the DRGs database.

METHODS

Of the 1519 children from the "Cohorte Enfant Scanner", who had had a CT scan in the radiology department of a university hospital in 2002, a cross linkage was performed with the DRGs database. All hospitalizations over the period 2002-2009 were taken into account. An algorithm was constructed for the items "cancer" and "disease at risk for cancer" on a sample of 150 children. The algorithm was then tested on the entire population.

RESULTS

Overall, 74% of our population was identified in the DRGs database. The algorithm individualized cancer diagnoses with 91% sensitivity (95% confidence interval [95%CI]: 86%; 97%) and 98% specificity (95%CI: 97%; 99%) and 86% positive predictive value (95%CI: 80%; 93%). For the diagnosis of disease at risk for cancer, the sensitivity, specificity and positive predictive value were respectively 91% (95%CI: 84%; 98%), 94% (95%CI: 92%; 95%) and 52% (95%CI: 43%; 61%).

CONCLUSION

The DRG database identified with excellent sensitivity and specificity children with diagnoses of cancer or disease at risk for cancer. Hence, potential confounding factors related to the disease of the child can be taken into account for analyses performed with the cohort.

Diagnostic accuracy of magnetic resonance imaging for an acute pulmonary embolism: results of the 'IRM-EP' study

BACKGROUND

Magnetic resonance imaging (MRI) has not been validated as an alternative diagnostic test to computed tomography angiography (CTA) in patients with suspicion of a pulmonary embolism (PE).

OBJECTIVES

To evaluate performance of current MRI technology in diagnosing PE, in reference to a 64-detector CTA.

PATIENTS/METHODS

  Prospective investigation including 300 patients with a suspected PE, referred for CTA after assessment of clinical probability and D-dimer testing. MRI protocol included unenhanced, perfusion and angiographic sequences. MRI results were interpreted by two independent readers, to evaluate inter-reader agreement. Sensitivity and specificity were evaluated globally and according to PE location and to clinical probability category.

RESULTS

Of 300 enrolled patients, 274 were analyzed and 103 (37.5%) had a PE diagnosed by CTA. For patients with conclusive MRI results (72% for reader 1, 70% for reader 2), sensitivity and specificity were 84.5% (95% confidence interval [CI], 74.9-91.4%) and 99.1% (95% CI, 95.1-100.0%), respectively, for reader 1, and 78.7% (95% CI, 68.2-87.1%) and 100% (95% CI, 96.7-100.0%) for reader 2. After exclusion of inconclusive MRI results for both readers, inter-reader agreement was excellent (kappa value: 0.93, 95% CI: 0.88-0.99). Sensitivity was better for proximal (97.7-100%) than for segmental (68.0-91.7%) and sub-segmental (21.4-33.3%) PE (P < 0.0001). Sensitivity was similar for both readers within each clinical probability category.

CONCLUSIONS

Current MRI technology demonstrates high specificity and high sensitivity for proximal PE, but still limited sensitivity for distal PE and 30% of inconclusive results. Although a positive result can aid in clinical decision making, MRI cannot be used as a stand-alone test to exclude PE.

[Hyperuricemia in sickle cell disease in France]

PURPOSE

Hyperuricemia has been reported to be a common feature of sickle cell disease occurring between 32 to 41% of the patients, in studies conducted during the 1970's. Since then, this notion has been rarely challenged. The objective of this study was to assess the prevalence of hyperuricemia and gout in adult patients with sickle cell disease in France.

METHODS

Between May 2007 and March 2009, serum and urinary urate concentration, creatininemia and hemogram were prospectively assessed in all consecutive sickle cell patients, followed in our sickle cell disease centre. All subjects were in a clinically steady state. Clinical acute gout history was also recorded.

RESULTS

Sixty-five patients (mean age 31±10.3 years) were investigated. Mean uric acid serum level was 281.6±74μmol/L. Hyperuricemia was evidenced in six patients only (9.2%) (95% IC: 3.5-19.0). None of the patient had a medical history of acute gout. Patients in the higher serum uric acid tertile concentration had higher serum creatinine level (62.3±17.1μmol/L vs 51.5±12.6μmol/L, P<0.01), lower fractional excretion of urate (4.5% vs 6.8%, P<0.03) and higher reticulocyte count (median 219500/mm(3) vs 144000/mm(3), P=0.08) compared to the other patients.

CONCLUSION

Hyperuricemia and gout are not a clinical problem in sickle cell disease in our country. Nevertheless, our findings indicate that kidney function has to be fully explored if serum uric acid level is elevated or significantly deteriorates during follow-up. Serum uric acid level could be an early marker of renal dysfunction in sickle cell disease patients.