Robot assisted radical prostatectomy in fit older patients compared to a standard population: Clinical characteristics, surgical, oncological and functional outcomes

INTRODUCTION

To compare robotic assisted radical prostatectomy (RARP) in well-selected older patients with clinically localized prostate cancer, compared to a younger population. Primary endpoint was perioperative outcomes comparison and secondary endpoint were oncological and functional outcomes comparison to a younger population.

METHODS

Single tertiary center cohort of consecutive patients treated with RARP (2017-2020) with retrospective analysis. Patients were classified by age in two groups: <75: control group (CG) and ≥75: study group (SG). Patients aged ≥75 had a comprehensive geriatric assessment (CGA) and only patients classified Balducci ≤2 were admitted to surgery.

RESULTS

Two hundred and sixty-nine patients were included, 56 in SG and 213 in CG. Median follow-up was 9.8 months. Univariate analysis showed no statistically significant (SS) difference between the groups for patients' characteristics (PSA, digital rectal examination -DRE- and biopsy Gleason Score), perioperative data (operative time, hospitalization length, transfusions rate, immediate complications, Clavien-Dindo complications, 30-days re-interventions and 30-days re-hospitalisation), oncological (TNM, margins, extraprostatic extension, postoperative PSA, BCR, metastases, overall survival -OS- and cancer specific survival -CSS-) and functional outcomes. Median perioperative blood loss was lower in the SG: 200.00 cc IQR [100.00, 300.00] vs 200.00cc IQR [100.00, 400.00] in the CG (P<0.05). A multivariate regression considering age>75, DRE, GS, PSA, cardiovascular history and diabetes showed none of variables associated with early BCR. Limitations are retrospective design, small number of patients and short follow-up.

CONCLUSIONS

RARP shows similar perioperative, oncologic and functional outcomes for older patients selected by a CGA when compared to younger patients. The SG shows a minor perioperative bleeding.

LEVEL OF EVIDENCE

IV.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Surgery under COVID: An observational study

AIM

To evaluate the surgery program strategy adopted in an adult otorhinolaryngology and head and neck surgery department in an area badly affected by the Covid-19 epidemic peak. The main objective was to analyze the reasons for not cancelling surgeries and the postoperative course of operated patients. The secondary objective was to assess the situation of postponed patients.

MATERIAL AND METHODS

A single-center observational study carried out during the COVID-19 period in France included 124 patients scheduled for surgery during the period March 21-May 20, 2020. The number and nature of operations, both performed and postponed, were reviewed.

RESULTS

A total of 54.0% patients were operated on during the COVID period and 46.0% were postponed. Operations were maintained in urgent or semi-urgent cases. The operated patients did not show any signs of infection during their hospital stay. A total of 29.8% of postponed patients were lost to follow-up and 49.1% were rescheduled.

CONCLUSION

The application of national and international recommendations minimized the risk of loss of chance for operated patients without increasing the risk of contamination. The postponement of canceled operations resulted in considerable loss to follow-up. Intensified follow-up is necessary for these patients.

État de connaissance des médecins urgentistes sur la prise en charge des intoxications au monoxyde de carbone en région Auvergne-Rhône-Alpes

Objectif : L’intoxication au monoxyde de carbone (ICO) est un diagnostic souvent difficile en urgence. Son incidence restant faible, les médecins urgentistes (MU) y sont rarement confrontés mais la pertinence de leur prise en charge est essentielle pour limiter la morbi-mortalité. L’objectif principal de cette étude était d’évaluer le niveau de connaissance des MU sur la prise en charge des ICO dans une région française de 8,1 millions d’habitants. L’objectif secondaire était d’individualiser les facteurs associés à une bonne connaissance de la prise en charge en urgence de cette pathologie.

Matériel et méthodes : Étude descriptive multicentrique et déclarative, réalisée auprès de MU travaillant au sein de cette région à l’aide d’un questionnaire en ligne.

Résultat : 246 MU ont répondu à l’enquête, représentant 82 % des structures de médecine d’urgence de la région. Parmi eux, 27 % estimaient prendre en charge moins de deux ICO par an. Le protocole territorial était connu par 59 % des répondeurs. La médiane de réponses justes au questionnaire de connaissance était de 43 [40-47] sur 60. Un taux de réponses justes plus faible (< 70 %) était retrouvé sur les questions traitant du diagnostic (65 %) et des indications et contre-indications de l’oxygénothérapie hyperbare (61 %). Les facteurs associés à un meilleur taux de réponses justes étaient : la connaissance du protocole territorial (63 vs 46 %, p = 0,035), une ancienneté d’exercice ≥ 5 ans (60 vs 40 %, p = 0,014), une formation complémentaire à la médecine hyperbare (85 vs 53 %, p = 0,018), un nombre estimé de prise en charge d’ICO ≥ 2 (60 vs 43 %, p = 0,022) et une auto-évaluation de ses connaissances > 7/10 (68 vs 50 %, p = 0,007).

Conclusion : Cette étude a montré un niveau de connaissance perfectible des MU sur cette pathologie en rapport avec un faible nombre de prise en charge annuel. La création d’un consensus national est à encourager pour améliorer les pratiques.

Auditory performance after cochlear reimplantation

AIM

The aim of this study was to evaluate the impact of cochlear reimplantation (CR) on hearing performance in children and adults with severe to profound hearing loss.

MATERIAL AND METHODS

Retrospective observational study.

OBJECTIVES

The main objective of this study was to determine whether there was a difference in hearing performance before and after CR. Secondary objectives were to analyze reasons for CR; to assess correlations between auditory performance and complete electrode reinsertion during CR, age, gender, explantation-to-CR interval, and interval between first implantation and CR; and to assess difference in APCEI score and the French evaluation protocol for implanted patients before and after CR.

RESULTS

Comparison of speech perception scores before and after explantation-reimplantation showed no significant difference (P>0.005) at 1 year or at 2 years after CR. In 80% of cases, reimplantation was due to hard implant failure. In other cases, it was undertaken for soft failure (diminished performance but no abnormalities on integrity testing) (8%), medical reasons (6%), or undetermined reasons (6%). There was no significant correlation between auditory performance at 1 or 2 years and complete or incomplete reinsertion of electrodes, age, gender, explantation-to-CR interval, or interval between first implantation and CR (P>0.005). For the adult subgroup, the French evaluation protocol scores did not differ after reimplantation (P=0.62). Likewise, for the child sub-group, APCEI and CAP results did not deteriorate after reimplantation.

CONCLUSION

Reimplantation had no negative impact on hearing and speech perception, but provided performance equivalent to or better than after initial implantation.

Asylum seekers’ and refugees’ understanding of government restrictions during the COVID-19 pandemic

Background

Asylum seekers and refugees risk poorer public health information and difficulties to follow measures during the COVID-19 pandemic because of language, cultural, administrative barriers and social insecurity. We investigate their attitudes and knowledge about COVID-19 measures.

Methods

A cross-sectional survey conducted between August and October 2020 in the canton of Vaud, Switzerland. The 24 questions covered health literacy, perception of the pandemic, understanding of health measures and adherence to conspiracy theories. The questionnaire was translated into the ten most common languages. It was distributed online through social networks of charitable and public organisations and in paper in asylum centres. Associations between participants responses and their characteristics were studied using multivariable logistic regressions.

Results

The 242 respondents had a mean age of 33 years, 63% were men and 42% had low health literacy. They were 16% asylum seekers, 45% temporarily admitted persons, 12% refugees and 26% rejected asylum seekers. All languages were used.

Self-reported adherence to recommendations was 82%. Respectively, 39% and 31% of participants reported sleep disorders or fear of dying. Adjusted for age, gender, health literacy and French language skills, rejected asylum seekers were less worried about the pandemic (aOR 0.37, p = 0.007) and more sensitive to conspiracy theories (aOR 3.47, p = 0.006) than other respondents. They also reported lower adherence to recommendations (aOR 0.45, p = 0.034).

Conclusions

We contribute new knowledge about a varied group of vulnerable persons under precarious conditions during the COVID-19 pandemic. The network based multi-language survey combining online and center based distribution was useful but also tedious. Our results highlight the low health literacy of asylum seekers and refugees and their deep concerns about the pandemic. Public health messages should be adapted to rejected asylum seekers.

Key messages

Asylum seekers and refugees have deep concerns about the Covid-19 pandemic (including sleep disorders and fear of dying) but a low health literacy. Public health messages should be adapted to socially vulnerable groups, especially rejected asylum seekers.

Évaluation médico-economique de l’impact de mesures d’adaptation au virage de la chirurgie robot-assistée en urologie

INTRODUCTION

The development of robot-assisted urological surgery is held back by the lack of robust medico-economic analyses and their heterogeneity. We conducted a medico-economic study to evaluate the implementation of measures to optimize the transition to robotic surgery.

METHOD

We carried out a single-center, controlled study from the point of view of the public healthcare establishment for 4 years. Economic data collection was based on a micro-costing method and revenues from stay-related groups. Clinical data corresponded to mean lengths of stay, operating duration, complications and stays in intensive care. The measures to optimize the transition to robotic, implemented mid-study period, enabled before/after comparison.

RESULTS

Altogether, 668 patients undergoing robotic surgery were included. Robotic activity increased significantly from periods 1 to 2 to 256% (P=<0.001) as did the overall proportion of robotic by 45% to 85% (P=<0.001). The mean lengths of stay fell significantly, 6.8 d vs. 5.1 d (P<0.001). Costs and revenues increased significantly, resulting in a persistent deficit for the activity €226K vs. €382K (P=<0.001). With increased volume of activity, the deficit per operation and the cost per minute of robotic operating room fell significantly, €3,284 vs. €1,474/procedure (P=<0.001) and €27 vs €24/min (P=<0.029), tending towards a break-even point (=zero deficit) at 430 operations per year.

CONCLUSIONS

Robotic-assisted surgery can be significantly optimized by implementing measures for the robotic turn to reach a break-even point at 430 operations per year. A better multidisciplinary case mix could lower the break-even volume of activity in short term.

LEVEL OF EVIDENCE

3.

The Anti-inflammatory Effect of the Tricyclic Antidepressant Clomipramine and Its High Penetration in the Brain Might Be Useful to Prevent the Psychiatric Consequences of SARS-CoV-2 Infection

At the time of writing (December 2020), coronavirus disease 2019 (COVID-19) has already caused more than one million deaths worldwide, and therefore, it is imperative to find effective treatments. The “cytokine storm” induced by Severe Acute Respiratory Syndrome-Coronavirus type 2 (SARS-CoV-2) is a good target to prevent disease worsening, as indicated by the results obtained with tocilizumab and dexamethasone. SARS-CoV-2 can also invade the brain and cause neuro-inflammation with dramatic neurological manifestations, such as viral encephalitis. This could lead to potentially incapacitating long-term consequences, such as the development of psychiatric disorders, as previously observed with SARS-CoV. Several pathways/mechanisms could explain the link between viral infection and development of psychiatric diseases, especially neuro-inflammation induced by SARS-CoV-2. Therefore, it is important to find molecules with anti-inflammatory properties that penetrate easily into the brain. For instance, some antidepressants have anti-inflammatory action and pass easily through the blood brain barrier. Among them, clomipramine has shown very strong anti-inflammatory properties in vitro, in vivo (animal models) and human studies, especially in the brain. The aim of this review is to discuss the potential application of clomipramine to prevent post-infectious mental complications. Repositioning and testing antidepressants for COVID-19 management could help to reduce peripheral and especially central inflammation and to prevent the acute and particularly the long-term consequences of SARS-CoV-2 infection.

[Outcomes following the triage of patients for urological cancer and non-cancer surgery during Covid-19 pandemic peak]

Introduction

Lors de la première vague épidémique Covid-19, des mesures de triage, sans PCR systématique, étaient mises en place pour sélectionner les patients à opérer. Notre étude a comparé leurs résultats chirurgicaux après triage à ceux d’un groupe contrôle.

Matériel

L’analyse portait sur l’ensemble des patients initialement programmés dans un centre Covid de référence et inclus consécutivement, du 15 mars au 1^er mai 2020 (NCT04352699). Leurs données étaient recueillies prospectivement et ultérieurement comparées à celles des patients opérés 1 an auparavant sur la même période dans ce centre. Le critère d’évaluation principal était l’admission post-opératoire en unité de soins intensifs (USI). La morbidité, la mortalité postopératoire, le report d’interventions, les tests PCR étaient évalués. Des analyses de sous-groupes étaient réalisés pour les patients opérés de cancer.

Résultats

Après triage, 96 des 142 interventions programmées ont dû être reportées. Sur les opérés, 48 (68 %) l’étaient pour cancer. Au total, aucun cas de pneumonie Covid-19 post-opératoire n’a été identifié. Trois patients (4 %) ont été admis en USI, dont un finalement décédé pour sepsis urinaire. Chez ces patients, les RT-PCR étaient négatives. Globalement, comparativement au groupe contrôle, aucune différence d’admission en USI, ni de taux de mortalité post-opératoire n’ont été rapportées.

Conclusions

Le triage de la première vague n’a pas surexposé les patients sélectionnés à un risque de complication ou de décès post-opératoire, particulièrement pas pour ceux opérés pour cancer. En revanche, 67 % des patients ont été reportés, avec un risque associé à des retard de soins pouvant conduire au décès.

Niveau de preuve

3.

[ECMO for post cardiotomy refractory cardiogenic shock: Experience of the cardiac surgery department of the Grenoble Alpes University Hospital]

OBJECTIVE

The objective of our study is to detail our experience relating to ECMO implantations for post-cardiotomy refractory shock, by analyzing the pre-ECMO factors (history, type of surgery, LVEF), factors relating to ECMO (implantation time, duration) and post-ECMO factors (weaning, complications) in order to highlight those possibly associated with high mortality.

METHODS

This is a univariate and multivariate retrospective study of ECMO data implemented between 2011 and 2019 at the Grenoble Alpes University Hospital Center following cardiac surgery. The time to implantation of ECMO was less than 3hours (intraoperative) between 3 and 24hours (early postoperative) and between 24 and 48hours after aortic unclamping (late postoperative). Preoperative or postoperative intra-aortic balloon counterpulsation (CPBIA) could be associated.

RESULTS

114 veino-arterial ECMOs were implanted for refractory cardiogenic shock after 5702 cardiac surgeries (1.9%) with a survival rate of 30.7%. The mean age of the patients was 68.6+- 10.5 years. The implantation of ECMO was performed intraoperatively in 71 patients (62.2%), early postoperatively in 22 patients (19.2%) and late postoperatively in 21 patients (18.4%). The duration of assistance was less than 48hours in 27 patients (23.6%), between 48hours and one week in 58 patients (50.9%) and more than one week in 29 patients (25.5%). Univariate analysis revealed a statistically significant association between mortality rate and male sex (P=0.002), association absent with other preoperative characteristics, delay in implantation of ECMO, installation of CPBIA, post-operative characteristics and resuscitation suites. Multivariate analysis of the entire study population demonstrated that the use of ECMO for cardio-respiratory arrest was the only independent risk factor for mortality (OR=7.57 [1.41-40, 62]). After multivariate reanalysis excluding patients with ECMO placement for cardio respiratory arrest, age, preoperative renal failure, type of procedure and EuroSCORE II were risk factors for mortality.

CONCLUSION

In this study, male gender, type of intervention, occurrence of cardiac arrest were significantly associated with the death rate. A study of greater power, multicentric, and with a larger sample, will have to be carried out to reach significance.

Early postoperative bleeding after isolated coronary bypasses: Changes over a period of 20 years - An observational study

OBJECTIVES

The objectives were to analyze the evolution of the postoperative bleeding after coronary artery bypass grafting and to determine which factors impacted on this evolution.

METHODS

This is a single-center retrospective study including 4590 patients undergoing coronary bypass surgery between 1995 and 2017. The study period was divided into 3 same-sized periods. We analyzed the evolution of the bleeding according to: the chest volume bleeding over the first 24hours, the severity and the rate of transfusion during the hospital stay. Intrahospital outcomes were compared between "minor" and "major" bleedings. The risk factors of major bleeding were analyzed by multiple logistic regression.

RESULTS

The chest volume decreased particularly during the first years of the study period. Major bleedings decreased over the periods (7.3%, 4.9% and 3.8% respectively, P<0.0001), as did the rate of transfusion (26.4%, 23.5% and 19.6% respectively, P<0.0001). Major bleedings were correlated with hospital mortality (8.2% versus 1.1%, P<0.0001). The risk factors of major bleeding were the period 1 (1995 to 2003), a renal failure, a resternotomy, the EuroSCORE, the hematocrit prior to cardiopulmonary bypass and the duration of cardiopulmonary bypass.

CONCLUSIONS

Postoperative bleeding decreased mainly in the 1990s. Progressive changes in bleeding prevention and blood recovery, surgical techniques, haemoglobin threshold for transfusion decision and practitioners' experience have contributed to these results and must be continued to optimize the postoperative outcomes.

Growth charts in Cockayne syndrome type 1 and type 2

Cockayne syndrome (CS) is a multisystem degenerative disorder divided in 3 overlapping subtypes, with a continuous phenotypic spectrum: CS2 being the most severe form, CS1 the classical form and CS3 the late-onset form. Failure to thrive and growth difficulties are among the most consistent features of CS, leaving affected individuals vulnerable to numerous medical complications, including adverse effects of undernutrition, abrupt overhydration and overfeeding. There is thus a significant need for specific growth charts. We retrospectively collected growth parameters from genetically-confirmed CS1 and CS2 patients, used the GAMLSS package to construct specific CS growth charts compared to healthy children from WHO and CDC databases. Growth data were obtained from 88 CS patients with a total of 1626 individual growth data points. 49 patients were classified as CS1 and 39 as CS2 with confirmed mutations in CSB/ERCC6, CSA/ERCC8 or ERCC1 genes. Individuals with CS1 initially have normal growth parameters; microcephaly occurs from 2 months whereas onset of weight and height restrictions appear later, between 5 and 22 months. In CS2, growth parameters are already below standard references at birth or drop below the 5th percentile before 3 months. Microcephaly is the first parameter to show a delay, appearing around 2 months in CS1 and at birth in CS2. Height and head circumference are more severely affected in CS2 compared to CS1 whereas weight curves are similar in CS1 and CS2 patients. These new growth charts will serve as a practical tool to improve the nutritional management of children with CS.

Determinants of doctors' antibiotic prescriptions for patients over 75 years old in the terminal stage of palliative care

INTRODUCTION

Notwithstanding high prevalence of presumably bacterial infections in elderly persons (EP) in palliative care (PC), there exists no recommendation on the role of antibiotic therapy (ABP) in this type of situation.

OBJECTIVE

To describe the determinants of antibiotic prescription by general practitioners (GP) and by doctors practicing in institutions (DPI) for patients>75 years, in end-of-life situations in PC.

METHOD

Descriptive investigation by anonymous self-administered questionnaire disseminated in France by e-mail.

RESULTS

A total of 301 questionnaires analyzed: 113 GP, 188 DPIs. The latter were mainly geriatricians (69, 36.6%) and infectologists/internists (41, 21.8%). Sixty-three (55,75%) GPs and 144 (78.7%) DPIs stated that they had prescribed antibiotics. Practice in "EHPAD" retirement homes or intensive care was often associated with non-prescription of antibiotics. Age, PC training and number of patients monitored bore no influence. Family involvement in decision-making was more frequent for GPs than for DPIs. The main purpose of antibiotic therapy was to relieve different symptoms (fever, respiratory congestion, functional urinary signs). Most of the doctors (81%) had previously encountered complications (allergy, adverse effect), which represented the main causes of treatment discontinuation.

CONCLUSION

Antibiotic use in end-of-life EPs in PC seems frequent. In accordance with the principle of beneficence, its goal of often symptom-related; that said, in the absence of scientific data, antibiotic prescription in end-of-life situations should be individualized in view of observing the other ethical caregiving principles (beneficence, non-maleficence, justice, patient autonomy) and re-evaluated daily.

[Urodynamics: All the nurse needs to know]

Urodynamic (UD) is an exam intended to explore the mechanisms underlying lower urinary tract symptoms (LUTS) or urinary incontinence (UI). It involves the measurement of bladder and sphincter pressures using uretrovesical and rectal catheters with pressure transducers, but also the measurement of urinary flow and bladder sensation during filling. UD is far from being systematic in the assessment of LUTS or UI and must seek to tackle a specific clinical or therapeutic question. Thus, history taking, physical examination, voiding diary and questionnaires are essential prerequisites to UD per se. UD steps include a free (unintubated) uroflowmetry, a cystometry, post-void residual measurement±an urethral profilometry, a pressure-flow study or sensitization tests. The pressures are set to zero before to start the study and the validity of the equipment is tested. This control is continued throughout the procedure to ensure the quality of the recording. Any event (e.g., urine leakage, change of position, urgency) is noted during the study. A final report is made by the doctor. The competence of the nurse ensures the reliability, reproducibility and interpretability of the UD study and the nurse's humanity guarantee f an atmosphere as favourable as possible for this uncomfortable and invasive test.