Role of thyroid dysimmunity and thyroid hormones in endometriosis.

Endometriosis is characterized by the presence of ectopic endometrial cells outside the uterine cavity. Thyroid autoimmunity has been associated with endometriosis. This work investigated the potential pathophysiological link between endometriosis and thyroid disorders. Transcripts and proteins involved in thyroid metabolism are dysregulated in eutopic and ectopic endometrium of endometriotic patients, leading to resistance of ectopic endometrium to triiodothyronine (T3) action and local accumulation of thyroxine (T4). Thyroid-stimulating hormone (TSH) acts as a proliferative and prooxidative hormone on all endometria of endometriosis patients and controls, whereas T3 and T4 act to specifically increase ectopic endometrial cell proliferation and reactive oxygen species (ROS) production. Mouse studies confirmed the data gained in vitro since endometriotic implants were found to be bigger when thyroid hormones increased. A retrospective analysis of endometriosis patients with or without a thyroid disorder revealed an increased chronic pelvic pain and disease score in endometriotic patients with a thyroid disorder.

Readmissions After Surgery: A French Nationwide Cross-Sectional Study of 1,686,602 Procedures Performed in 2010.

BACKGROUND: Surgical readmissions have been extensively studied in North America, but very few data from other countries are available. We aimed to describe surgical readmissions in France and to assess their association with hospital status, surgical volume, and day surgery activity. METHODS: We performed a cross-sectional study encompassing all 1270 French hospitals, except for military hospitals and hospitals with very small volume. Data were retrieved from the national database regarding all patients undergoing surgery between January 1, 2010 and November 30, 2010. The main outcome measure was 30-day readmission rate. Association with hospital status, surgical volume, and the level of day surgery were assessed. Risk adjustment was performed based upon administrative categories. RESULTS: After exclusion of deaths and hospital transfers, there were 1,686,602 patients in the study cohort. Thirty-day readmission rate was 5.9 %. Distribution was skewed, with 21.5 % of procedures accounting for 33.5 % of all 30-day readmissions. Early readmissions (≤3 days) were associated with higher mortality as compared to those occurring later (>7 days) (3.2 vs. 2.6 %; p < 0.0001). After multivariate analysis, University hospitals were shown to be affected by a significantly greater risk of 30-day readmission as compared to private hospitals (odds ratio 1.46 [95 % CI 1.42-1.5]). Other independent factors were as follows: male gender, longer initial hospital stay, and comorbidities. CONCLUSIONS: Surgical 30-day readmission rate was low, with early readmissions being associated with higher mortality. Conversely to prior research, University hospitals were shown to be associated with significantly higher risk of 30-day readmissions, even after risk adjustment.

Impact of resident and fellow changeovers on patient outcomes: a nationwide cross-sectional study.

Background: Findings regarding the association of cohort changeovers with patient outcomes are mixed. We sought to examine the association of resident and fellow changeovers with a comprehensive set of indicators. Methods: We performed a cross-sectional comparative study including all French teaching and non-teaching hospitals. All-cause mortality and length of stay were assessed. Focused analysis for three medical conditions (myocardial infarction, intestinal hemorrhage, stroke) and three surgical procedures (colorectal, vascular and spine surgery) was performed regarding other quality and efficiency indicators (readmissions, intensive care unit admission, transfers). Results: Overall, 34 330 716 patients were admitted in 2011 and 2012. Within the month following cohort changeovers, no increase in mortality was observed in teaching hospitals. Length of stay was longer in May and November in teaching hospitals (P < 0.0001) whereas it was shorter in the private sector. When focusing on six selected causes of hospitalization, we observed significant differences associated with resident changeovers, suggesting a decreased efficiency. In particular, readmissions rates and lengths of stay were found to be significantly higher (P < 0.0005) after intestinal hemorrhage and with a trend toward worse efficiency (P < 0.005) after colorectal surgery and stroke in teaching hospitals. Conclusion: Our findings provide some reassurance regarding cohort changeover and mortality even if they suggest a loss of efficiency in some cases.

Restorative Proctocolectomy and Ileal Pouch-anal Anastomosis.

OBJECTIVES: To assess mortality after restorative proctocolectomy (RPC) and determine the influencing factors with a specific focus on institutional caseload and surgical approach in France. BACKGROUND: RPC is an uncommonly performed and demanding procedure; case volume may exert a significant influence on outcome. METHODS: Data of all patients who underwent RPC in France between 2009 and 2012, including demographics, diagnosis, procedures, mode of admission, discharge, and hospital type were collected. RESULTS: One thousand one hundred sixty-six RPCs were performed in 237 centers (mean: 1.65 procedure/year/center). Rate of laparoscopic procedures was 47.1% (n = 549). Mortality reached 1.5% (n = 17). Independent factors for mortality were ageless than 45 years (odds ratio, OR = 3.9) and surgery in a center performing less than 3 RPC per year (OR = 3.2). Centers performing less than 3 RPC per year represented 89% of all centers, accounted for 37% (n = 431) of all patients and represented 70.6% of all deaths (n = 12). Underlying pathology exerted a significant effect on mortality; mortality rate after "classical" indications (polyposis and inflammatory bowel disease) was 0.7% (8/1078) and was 16.7% (9/54) for "nonclassical" indications (peritonitis, carcinomatosis, and so on) (P < 0.0001). Nonclassical diagnoses were observed more frequently in centers performing less than 3 RPC per year [40/412 (7.3%) vs 24/720 (3.3%), P = 0.0027]. A laparoscopic approach was associated with a low mortality rate on univariate analysis (0.7% vs 1.2%, P = 0.05), a shorter hospital stay (15.8 ±â€Š0.6 vs 17.8 ±â€Š0.55, P = 0.0053) and more frequently performed in experienced centers ≥3 RPC/year (50.8% vs 40.7%, P = 0.0009). CONCLUSIONS: Mortality after RPC in centers performing 3 or less RPC per year was significantly higher, and accounted for more than half of all deaths. In France, consolidating all RPCs to higher volume centers may lead to better outcomes.

Antimicrobial stewardship in high-risk febrile neutropenia patients.

BACKGROUND: The 2011 4th European Conference on Infections in Leukemia (ECIL4) guidelines recommend antibiotics de-escalation/discontinuation in selected febrile neutropenia (FN) patients. We aimed to assess the impact of an antimicrobial stewardship (AMS) program based on these guidelines on antibiotics use and clinical outcomes in high-risk FN patients. METHODS: We conducted an observational study in the hematology department of Cochin University Hospital in Paris, France. An ECIL4-based antibiotics de-escalation and discontinuation strategy was implemented jointly by the hematologists and the AMS team. The pre-intervention (January-October 2018) and post-intervention (January-October 2019) periods were compared. We retrospectively collected clinical and microbiological data. We compiled antibiotics consumptions via hospital pharmacy data and standardized them by calculating defined daily doses per 1000 patient-days. We analyzed the two-monthly antibiotic consumption using an interrupted time series method and built a composite endpoint for clinical outcomes based on transfer to the intensive care unit (ICU) and/or hospital death. RESULTS: Overall, 273 hospital stays (164 patients) in the pre-intervention and 217 (148 patients) in the post-intervention periods were analyzed. Patients were mainly hospitalized for intensive chemotherapy for acute leukemia or autologous stem-cell transplant for myeloma. Patients were slightly younger in the pre-intervention compared to the post-intervention period (median age 60.4 vs 65.2 years, p = 0.049), but otherwise comparable. After implementation of the AMS program, glycopeptide and carbapenem use decreased by 85% (p = 0.03) and 72% (p = 0.04), respectively. After adjustment on confounders, the risk of transfer to the ICU/death decreased significantly after implementation of the AMS program (post-intervention period: odds-ratio = 0.29, 95% Confidence Interval: 0.15-0.53, p < 0.001). CONCLUSION: Implementation of a multidisciplinary AMS program for high-risk neutropenic patients was associated with lower carbapenem and glycopeptide use and improved clinical outcomes.

Prevalence and predictive factors for the detection of carcinoma in cavity margin performed at the time of breast lumpectomy.

Margin resection status is a major risk factor for the development of local recurrence in breast conservation therapy for carcinoma. Tumor bed excision sent as separate orientated cavity margins represents a tool to verify the completeness of the carcinoma resection. We aimed to (1) determine the prevalence of positive cavity margin and its influence on subsequent surgical treatment and (2) identify potential predictive factors for positive cavity margins. From 2003 to 2006, 107 (57 years; 30-88) consecutive patients who underwent a lumpectomy for carcinoma with four orientated cavity margins for carcinoma were selected. Preoperative clinical, radiological and histological data, perioperative macroscopic characteristics and definitive histological analysis results were recorded. Lumpectomy or cavity margins were considered as positive when the distance from carcinoma to the margin was less than or equal to 3 mm. Histological examination of cavity margins showed carcinoma in 38 patients (35%), therefore modifying subsequent surgical therapy in 33 cases. Examination of the cavity margins led (1) to avoiding surgical re-excision in 20 cases (lumpectomy margins were positive and the cavity margins negative), (2) to performing a mastectomy or a re-excision in 13 cases (carcinoma was detected in the cavity margins although the lumpectomy margins were negative or tumor size was superior to 3 cm). Between preoperative and perioperative parameters, US scan and macroscopic size of the tumor were predictive factors for positive cavity margins whereas characteristics of the carcinoma determined on biopsy samples and macroscopic status of the lumpectomy margins were not. Our study confirms that the systematic practice of cavity margin resection avoids surgical re-excision and reduces the likelihood of underestimating the extent of the tumor.

Hospital Readmissions After Urological Surgical Procedures in France: A Nationwide Cohort Study over 3 Years.

BACKGROUND: Identifying the predictive factors for hospital readmission is required to target preventive measures. OBJECTIVE: To assess the rate of surgical readmissions after a urological procedure and the risk factors associated with readmission. DESIGN, SETTING, AND PARTICIPANTS: Data from all hospitalizations between January 2010 and November 2012 in France, regarding planned urological surgeries, were retrieved from the national medical database. To limit interactions between recent hospitalizations and surgical interventions, we selected only patients who were not hospitalized during the 12 mo preceding the urological procedure. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary outcome was the rate of readmissions within 30 d after urological surgery. The following risk factors for readmission were assessed: sex, age, diagnosis-related group, length of stay of initial hospitalization, type of hospitalization (conventional or day surgery), hospital volume activity, hospital volume for day surgery, and hospital status. Logistic regression multivariate analysis was used to assess risk factors. RESULTS AND LIMITATIONS: Overall, 419 787 patients were included among whom 77 241 patients (18.40%) were readmitted within the following 30 d. After multivariate analyses, male sex (odds ratio [OR]=1.84, confidence interval [CI] 95%: 1.81-1.88), high level of comorbidity (diagnosis-related group 3-4 vs 1-2: OR=2.14, CI 95%: 2.10-2.21), and initial management in a private hospital (private vs university hospital: OR=1.13, CI 95%: 1.11-1.16; private vs public general hospital: OR=1.21, CI 95%: 1.18-1.23) were associated with a higher risk of readmission within 30 d. CONCLUSIONS: Reported readmission rate within 30 d after a planned a urological procedure was nearly 20%. PATIENT SUMMARY: In this French national study, we investigated the readmission rate within 30 d after a planned urological procedure in a large French population and discovered it was nearly 20%.

Impact of endogenous luteinizing hormone serum levels on progesterone elevation on the day of human chorionic gonadotropin administration.

OBJECTIVE: To assess the relationship between endogenous LH serum levels after GnRH analogue administration and serum P elevation on the day of hCG administration (P hCG). DESIGN: Retrospective study. SETTING: Reproductive medicine center in a university hospital. PATIENT(S): A total of 708 patients undergoing a GnRH agonist or antagonist protocol for IVF intracytoplasmic sperm injection. INTERVENTION(S): Controlled ovarian stimulation. MAIN OUTCOME MEASURE(S): Serum P values according to GnRH analogue; correlation between serum LH measurements and P hCG values. RESULT(S): Serum P hCG values were significantly lower following the GnRH antagonist than agonist protocol. A positive correlation between serum P hCG and LH area under the curve or day 6 LH values was found in the GnRH agonist group and between P hCG and LH hCG levels in both GnRH analogue regimens. With multivariate analysis, P hCG values were positively correlated with serum E(2) levels on hCG administration day and with the total FSH dose in both GnRH analogue-treated groups. Additionally, the correlation between serum P hCG and LH hCG values was positive in patients treated with the GnRH agonist protocol. CONCLUSION(S): The lower serum P levels on hCG administration day following the GnRH antagonist protocol are mainly explained by lower granulosa cell steroidogenic activity. The correlation with serum LH hCG values was positive in the GnRH agonist-treated group.