Intra- and inter-rater consistency of dual assessment by radiologist and neurologist for evaluating DWI-ASPECTS in ischemic stroke

OBJECTIVES

To estimate the intra -and inter-rater consistency of radiologist and neurologist working in pairs attributing DWI-ASPECTS (Diffusion Alberta Stroke Program Early CT Score) in patients with acute middle cerebral artery ischemic stroke referred for mechanical thrombectomy, intravenous thrombolysis or bridging therapy.

METHODS

Five neurologists and 5 radiologists working in pairs and in hour period scored independently and in two reading sessions anonymized DWI-ASPECTS of 80 patients presenting with acute anterior ischaemic stroke in our center. We measured agreement between pairs using intraclass correlation coefficients (ICCs). A Fleiss kappa was used for dichotomized (0-6;7-10) and trichotomized (0-3;4-6;7-10) ASPECTS. The interrater distribution of the score in the trichotomized (0-3;4-6;7-10) ASPECTS was calculated. We determined the interrater (Cohen kappa) and intrarater (Fleiss kappa) agreement on the ASPECTS regions.

RESULTS

The average DWI-ASPECTS was 6.35 (SD±2.44) for the first reading, and 6.47 (SD±2.44) for the second one. The ICC was 0.853 (95%CI, 0.798-0.896) for the interrater, and 0.862 (95%CI, 0.834-0.885) for the intrarater evaluation. Kappa coefficients were high for dichotomized (k=0.75) and trichotomized (k=0.64) ASPECTS. Evaluators agreement on the ASPECTS category (0-3), (4-6) and (7-10) was 88, 76 and 93% respectively. The anatomic region infarcted was well identified (k=0.70-0.77), except for the internal capsula (k=0.57). Interrater agreement was fair for M5 (k=0.37), moderate for internal capsula (0.52) and substantial for the other regions (0.60-0.79).

CONCLUSIONS

Reliability of DWI-ASPECTS is good when determined by radiologist and neurologist working in pairs, which corresponds to our current clinical practice. However, discrepancies are possible for cut-off determination, which may impact the indication of thrombectomy, and for the determination of the exact infarcted region. Agreement to propose category (4-6) is lower than for (0-3) and (8-10) ASPECTS categories.

Séroprévalence SARS-Cov-2 chez les professionnels de santé : étude multicentrique avec analyse des facteurs de risque professionnels et extraprofessionnels

Introduction

L’objectif de notre étude était d’évaluer la séroprévalence SARS-Cov-2 chez les professionnels de santé, après la première vague Covid-19, et d’analyser les facteurs professionnels et extraprofessionnels modifiant cette prévalence.

Matériels et méthodes

Suite aux instructions gouvernementales proposant de réaliser une sérologie Covid-19 à tout professionnel de santé après la première vague, nous avons réalisé une étude transversale, multicentrique. Tous les professionnels volontaires des quatre centres participants étaient invités à réaliser une sérologie et à remplir un questionnaire concernant leurs données démographiques, leurs caractéristiques professionnelles, l’utilisation des équipements de protection individuelle et l’exposition extra professionnelle au Covid-19. Nous avons calculé la prévalence SARS-Cov-2 et utilisé une régression logistique en appliquant un effet centre.

Résultats

Un total de 3454 professionnels ont participé à l’étude dont 83,4 % de femmes. L’âge moyen était de 40,6 ans [31,8–50,3]. En médiane, la prévalence sérologique SARS-Cov-2 était de 5 % (95 % IC, 4,3 %–5,8 %). Les facteurs associés à une plus forte séroprévalence étaient : l’âge < 30 ans (aOR = 1,59, (95 % IC, 1,06–2,37)), le statut d’étudiant (aOR = 3,38, (95 % IC, 1,62–7,05)) avec une séroprévalence de 16,9 % dans cette catégorie. L’unité de travail, y compris le fait d’avoir travaillé en unité Covid ou en réanimation, ainsi que l’exposition à des patients (quel que soit leur statut infectieux) n’étaient pas associé à une augmentation de la séroprévalence. Par contre les professionnels rapportant un contact avec un patient Covid, sans protection adaptée, ou ayant pratiqué des taches aérosolisantes, y compris avec un masque FFP2, avaient un surrisque d’infection Covid-19 (respectivement aOR à 1,66 et 1,7). Enfin, l’exposition à un collègue infecté ou à un cas familial était également associée à une augmentation de la prévalence sérologique.

Conclusion

Les mesures mises en place pour limiter la transmission du SARS-Cov-2 des patients aux professionnels de santé semblent efficaces. En complément de la vaccination, l’éviction systématique des professionnels infectés, la formation des étudiants et le rappel des mesures d’hygiène durant les temps de pause pourraient limiter la contamination des professionnels de santé.

Score for pulmonary tuberculosis in patients with clinical presumption of tuberculosis in a low-prevalence area

OBJECTIVES: To develop a diagnostic predictive model for the identification of patients with presumptive pulmonary tuberculosis (PTB) at high risk for active disease and those requiring nucleic acid amplification (NAAT) testing and/or preventive respiratory isolation in low-incidence, high-income countries.DESIGN: A 1:1 case-control study was conducted in consecutive immunocompetent patients with presumed PTB hospitalised between 2009 and 2012 in Paris, France. Cases were defined as individuals with culture-confirmed PTB, regardless of smear result. Those with presumed PTB and three smear- and culture-negative samples were selected as controls. A score was derived using conditional logistic regression. Internal validity of the score was assessed using the bootstrap method.RESULTS: A total of 354 patients were included in the analysis (177 cases, 177 controls). Among the 177 cases, 74 (42%) were smear-negative but culture-positive. Factors independently associated with PTB were age <50 years (adjusted OR [aOR] 4.7, 95%CI 1.8–12), diabetes (aOR 3.2, 95%CI 1.1–9.8), absence of cough with or without sputum (aOR 3.7, 95%CI 1.7–8.3), fever >15 days (aOR 3.5, 95%CI 1.3–9.5), apical infiltration without cavity (aOR 3.4, 95%CI 1.4–8.5) and cavitation or miliary pattern (aOR 19.7, 95%CI 7.6–51.1). Score C-index was 0.84 (95%CI 0.79–0.88). Calibration for the overall population (P = 0.770) and in smear-negative patients (P = 0.980) was appropriate. A score of 3.3 had 90% sensitivity, 50% specificity and 79% (IQR 28–95) median probability of PTB.CONCLUSIONS: This score could be used to build an algorithm to determine the need for respiratory isolation and/or NAAT use in PTB disease.

Infection recurrence factors in one- and two-stage total knee prosthesis exchanges

PURPOSE

Revision of infected total knee replacements (TKR) is usually delayed for a period in which the joint space is filled with an antibiotic-loaded acrylic spacer. In contrast, one-stage re-implantation supposes immediate re-implantation. Formal comparisons between the two methods are scarce. A retrospective multi-centre study was conducted to investigate the effects of surgery type (one-stage vs. two-stage) on cure rates. It was hypothesised that this parameter would not influence the results.

METHOD

All infected TKR, treated consecutively between 2005 and 2010 by senior surgeons working in six referral hospitals, were included retrospectively. Two hundred and eighty-five patients, undergoing one-stage or two-stage TKR, with more than 2-year follow-up (clinical and radiological) were eligible for data collection and analysis. Of them, 108 underwent one-stage and 177 received two-stage TKR. Failure was defined as infection recurrence or persistence of the same or unknown pathogens. Factors linked with infection recurrence were analysed by uni- and multi-variate logistic regression with random intercept.

RESULTS

Factors associated with infection recurrence were fistulae (odds ratio (OR) 3.4 [1.2-10.2], p = 0.03), infection by gram-negative bacteria (OR 3.3 [1.0-10.6], p = 0.05), and two-stage surgery with static spacers (OR 4.4 [1.1-17.9], p = 0.04). Gender and type of surgery interacted (p = 0.05). In men (133 patients), type of surgery showed no significant linkage with infection recurrence. In women (152 patients), two-stage surgery with static spacers was associated independently with infection recurrence (OR 5.9 [1.5-23.6], p = 0.01). Among patients without infection recurrence, International Knee Society scores were similar between those undergoing one-stage or two-stage exchanges.

CONCLUSION

Two-stage procedures offered less benefit to female patients. It suggests that one-stage procedures are preferable, because they offer greater comfort without increasing the risk of recurrence. Routine one-stage procedures may be a reasonable option in the treatment of infected TKR.

LEVEL OF EVIDENCE

III.

Prolonged delay for controlling KPC-2-producing Klebsiella pneumoniae outbreak: the role of clinical management

BACKGROUND

Carbapenemase-producing Enterobacteriaceae (CPE) are becoming of immediate concern for infection control policies. Prompt detection of CPE on health care setting admission is crucial to halt the spread of an outbreak. We report a cluster of 13 Klebsiella pneumoniae carbapenemase (KPC)-2-producing K pneumoniae cases in a tertiary care hospital.The objective of this study was to identify contributing factors originating the outbreak.

METHODS

An outbreak investigation was conducted using descriptive epidemiology, observation of health care practices, and interviews of management staff. A root cause analysis was performed to identify patent and latent failures of infection control measures using the association of litigation and risk management method.

RESULTS

The main patent failure was the delay in identifying KPC-2-producing K pneumoniae carriers. Contributing factors were work and environmental factors: understaffing, lack of predefined protocols, staff members' characteristics, and underlying patients' characteristics. Latent failures were as follows: no promotion of the national guidelines for prevention of CPE transmission, no clear procedure for the management of patients hospitalized abroad, no clear initiative for promoting a culture of quality in the hospital, biologic activity recently outsourced to a private laboratory, and poor communication among hospital members.

CONCLUSION

Clinical management should be better promoted to control hospital outbreaks and should include team work and safety culture.

Does the PFNA™ nail limit impaction in unstable intertrochanteric femoral fracture? A 115 case-control series

INTRODUCTION

Femoral neck shortening after dynamic fixation of extra-capsular fracture may impair functional results, but is rarely assessed. The present study measured impaction in stable and unstable fractures (on the Ender classification) treated by PFNA™ nail. The objectives were: 1) to validate the Ender classification to assess fracture stability; 2) to determine whether neck shortening and head purchase quality varied with stability; and 3) to determine the functional impact of femoral neck shortening.

HYPOTHESIS

The study hypothesis was that the PFNA™ nail stabilizes unstable as well as stable fractures.

MATERIALS AND METHODS

One hundred and fifteen consecutive patients, aged over 70 years, operated on for intertrochanteric fracture using the PFNA™ nail were followed up prospectively for 6 months. Multivariate analysis, including age, gender, assembly quality and body-mass index, was applied to assess the predictive power of the Ender classification with respect to femoral neck shortening. Secondly, patients were grouped according to stable versus unstable fracture (n=70 and 45, respectively), and impaction and femoral head purchase were assessed on a dedicated radiographic protocol. Functional results were assessed on Parker score.

RESULTS

In the unstable fracture group, 3 assembly failures required revision by total hip replacement. Ender grade>2 was significantly predictive of>5mm neck shortening. Neck shortening was greater in unstable fracture: 8.1 ± 8.4mm (range, 4-32 mm), versus 2.5 ± 3.7 mm (range, 3-14 mm) (P=0.0004). Mean blade cut-through was 1.2 ± 2.9 mm (range, 1-12 mm) in unstable fracture, versus 0.3 ± 1.3 mm (range, 1-6mm) (P=0.02). Mean cut-out was 2.3 ± 6 mm (range, 2-21 mm) in unstable fracture, versus 0.5 ± 2.6 mm (range, 1-8mm) (P=0.03). Parker scores diminished comparably in the two groups, without significant difference at follow-up: 3.9 ± 2.6 (range, 0-9) in stable and 3.1 ± 1.9 (range, 0-8) in unstable fracture; reduction in Parker score showed no correlation with femoral neck shortening (r=0.013, P=0.88).

DISCUSSION

The PFNA™ nail provides poorer stabilization of unstable compared to stable fracture. Femoral neck shortening should be taken into account in assessing internal fixation hardware perfomances.

LEVEL OF EVIDENCE

Level III. Prospective case-control study.