Why are people still dying of drug-susceptible TB in Paris in the 21st century?

BACKGROUND: Although the burden of TB is lower in France than in low-income countries, patients continue to die from TB in Paris. Our goal was to describe TB-related deaths and to identify associated risk factors.METHODS: We conducted a retrospective cohort study in two hospitals in Paris between 2013 and 2018. All patients with drug-susceptible TB were included and followed until end of treatment. The primary outcome was death. We performed univariate and multivariate analysis using Cox proportional hazard model.RESULTS: Of the 523 patients included, 362 were men (median age 37 years), of whom 24 patients died (4.5%). The final survival model concluded that age (HR 1.1 for each additional year), not living in one´s own accommodation (HR 5.9), being born in France (HR 8.0), being alcoholic (HR 4.2), having a history of cancer (HR 7.1) or meningeal or miliary TB (HR 8.2) were associated with a higher risk of death.CONCLUSION: The rate of TB-associated death is unacceptably high for a curable disease. To note, patients born in France were much more at risk of death than immigrants. We believe raising awareness among healthcare professionals is a potentially easy and efficient lever for improving care.

Tocilizumab and COVID-19: Timing of administration assessment.

Recent evidence showed greater efficacy of tocilizumab (TCZ) in the subgroups of COVID-19 patients who presented with symptoms for less than 7 days and in those only receiving oxygen. We retrospectively analyzed a compassionate use cohort to determine the best timing for TCZ injection. We showed no association between the timing of injection after symptom onset and the efficacy of TCZ on mortality. We then investigated whether the oxygen level at the time of TCZ injection impacted the mortality rate. Our study finally suggested that TCZ could be less effective when oxygen requirement is >11L/min and we hypothesized that earlier administration could be associated with better outcome. However, randomized clinical trials are required to confirm this hypothesis.

[The value of healthy skin biopsy in the diagnosis of intravascular B-cell lymphoma: A case report and systematic literature review]. / Intérêt de la biopsie cutanée en peau saine dans le diagnostic du lymphome B intravasculaire : cas clinique et revue systématique de la littérature.

BACKGROUND: Intravascular large B-cell lymphoma (ivLBCL) is a rare blood dyscrasia that is difficult to diagnose. Healthy skin biopsies may prove useful in diagnosis of the condition. Herein we report a case of ivLBCL diagnosed using this type of examination, and we provide a literature review to determine the sensitivity of such testing. PATIENTS AND METHODS: A 67-year-old woman was hospitalised for unexplained prolonged fever (UPF) and impaired general well-being. Laboratory tests revealed inflammatory syndrome, elevated LDH>2000IU/L, hepatic cytolysis and decreased prothrombin time at 47 %. Analysis for infection and medical imaging ruled out both an infectious or inflammatory origin and solid tumour. A healthy skin biopsy enabled confirmation of the diagnosis of ivLBCL. DISCUSSION: This clinical case illustrates the value of healthy skin biopsy in establishing a diagnosis of ivLBCL in patients hospitalised for UPF. Following a systematic literature review in PubMed/Medline, we included eight studies involving at least three patients designed to assess the value of healthy skin biopsy in the diagnosis of ivLBCL. The diagnostic sensitivity of this approach ranged from 67% to 100%, with a sensitivity of 100% being seen in four of the eight studies. Details of the biopsy sites were available in three studies and diagnostic sensitivity was similar overall between samples taken from the thigh, abdomen and arms. CONCLUSION: Healthy skin biopsy sampling from at least two sites constitutes a sensitive and relatively non-invasive procedure for early diagnosis of ivLBCL.

Invasive cervical cancer in HIV-infected women: risk and survival relative to those of the general population in France. Results from the French Hospital Database on HIV (FHDH)-Agence Nationale de Recherches sur le SIDA et les Hépatites Virales (ANRS) CO4 cohort study.

OBJECTIVES: We examined trends in the incidence rates of invasive cervical cancer (ICC) and in the rate of survival after ICC among women living with HIV (WLHIV) in France and compared them to those of the general population. METHODS: Histologically validated incident cases of ICC in the period 1992-2009 from the French Hospital Database on HIV (FHDH-ANRS CO4) were included in the study. Age-standardized incidence rates were estimated for FHDH and the general population in France for 1992-1996 [pre-combination antiretroviral therapy (cART) period], 1997-2000 (early cART period), 2001-2004 (intermediate cART period), and 2005-2009 (late cART period). Age-standardized incidence ratios (SIRs) were calculated. Five-year survival was compared with that of the general population for ICC diagnosed in 2005-2009 after standardization for age. RESULTS: Among 28 977 WLHIV, 60 incident ICCs were histologically validated. There was a nonsignificant decreasing trend for the incidence across the cART periods (P = 0.07), from 60 to 36/100 000 person-years. The risk of ICC was consistently significantly higher in WLHIV than in the general population; the SIR was 5.4 [95% confidence interval (CI) 3.0-8.9] during the pre-cART period and 3.3 (95% CI 2.2-4.7) in 2005-2009. Survival after ICC did not improve across periods (log-rank P = 0.14), with overall estimated 5-year survival of 78% (95% CI 0.67-0.89%). Five-year survival was similar for WLHIV and the general population for women diagnosed with ICC in 2005-2009, after standardization (P = 0.45). CONCLUSIONS: ICC risk is still more than three times higher in WLHIV than in the general population. Survival after ICC did not improve over time and was similar to that of the general population during the most recent period. Such results call for promotion of the uptake of screening in WLHIV.

Evolving microbiological epidemiology and high fetal mortality in 135 cases of bacteremia during pregnancy and postpartum.

The outcome of bacterial bloodstream infections during pregnancy has greatly improved over the last few decades. However, there are no recent data on the characteristics of bacteremia in pregnant women. The aim of this study was to describe clinical and microbiological features of bacteremia and to assess maternal and fetal outcome. This retrospective study was conducted in the obstetrics departments of five teaching hospitals in Paris, France, from 2005 to 2009. The incidence of bacteremia was 0.3%. The most common sources of bacteremia were chorioamnionitis (47%) and the most common pathogen isolated was Escherichia coli. Empirical antimicrobial therapy was inappropriate in 29% of bacteremia cases, mostly (65%) when secondary to infection with an aminopenicillin-resistant microorganism. Bacteremia during pregnancy was associated with a 10% fetal mortality. Bacteremia during pregnancy is a rare occurrence, but it is associated with an unexpectedly poor fetal outcome and a high mortality rate.

How to improve the quality of a disease management program for HIV-infected patients using a computerized data system. The Saint-Antoine Orchestra program.

OBJECTIVES: The emergence of non-AIDS-related events in the HIV-infected population experiencing a longer life expectancy implies the implementation of a comprehensive approach of HIV clinical management through better access to care, prevention, and early diagnosis of co-morbidities. METHODS: The Orchestra program is a computer-assisted HIV care and support tool implemented since December 2004 in the outpatient clinic of a University Hospital set in Paris, France. The intervention aims at improving access to HIV information care and support specifically targeted five areas of actions: cardiovascular risk factors; gynecological follow-up; anti-hepatitis B virus (HBV) vaccine coverage; sexuality and prevention of sexually transmitted infections; and compliance to antiretrovirals. The impact of this program was examined prospectively on a "before-after" basis after a two-year implementation. RESULTS: In the two-year period, 1717 patients were regularly followed. The level of the database information significantly increased in time (low density lipoprotein (LDL) cholesterol and glycemia were informed in 74% of patients at inclusion versus 95% at two years, and 83% versus 97%, p < 0.001, respectively). The number of targeted interventions was also higher. For eligible women, papanicolaou smears and mammography were prescribed in 52% of cases after intervention, versus 44% at inclusion, p0.04 and 83% versus 50%, p < 0.001, respectively. Indicators of care eventually improved significantly. Initially 72% non-adherent patients declared to be adherent after the intervention ( p < 0.001) and 67% of patients with initial LDL-hypercholesterolemia normalized their LDL level within two years ( p < 0.001). CONCLUSION: The Orchestra program has provided a unique opportunity to assess and improve prevention and management of co-morbidities in HIV patients.

[Early diagnosis and prevention of comorbidities among HIV-infected patients: the Orchestra Saint-Antoine Program]. / Dépistage et prévention des comorbidités chez les patients infectés par le VIH: le programme Orchestra Saint-Antoine.

OBJECTIVES: The Saint-Antoine Orchestra Program aims at improving the clinical management of HIV-infected patients through access to care, prevention and early diagnosis of comorbidities. METHODS: The program was initiated in December 2004 on the whole database. The following topics were concerned: cardiovascular risk factors, gynecological follow-up, anti-HBV vaccinal coverage, sexuality and prevention of STIs, therapeutic adherence and counsels to travelers. The program included several actions: diffusion of information to patients, development of a computerized chart (alert pop-ups), individualized prescription advice and recommendations for specialist referral. RESULTS: The program was applied to 1959 patients whose initial characteristics were: mean age: 43+/-10 years; ratio M/W: 1466/493; European origin: 69%; sub-Saharan: 19%; mean duration of HIV infection: 9.3+/-6 years; naïve of antiretrovirals: 14%; mean CD4+count: 494+/-277/mm(3); HIV viral load inferior to 50 cp/ml: 62%. Among 1347 patients for whom cardiovascular risk factors were completely informed, 42% had two or more factors. In particular, 31% of them were smokers, 7% had an arterial pressure superior to 140/90 mmHg and 11% had LDL-cholesterolemia superior to 4.1 mmol/l. Among 1448 untreated patients, 70% were initially considered as adherent. Half of the concerned women had neither cervical smear nor mammography up to date. Among 67% patients with an informed complete HBV serology, 27% were seronegative among which 310 (86%) were eligible for the vaccine. Problems of sexual difficulties or prevention were initially discussed for 11% of patients. Among them, 14% had a problem of prevention and 148 (66%) recognized sexual difficulties. CONCLUSION: The initiation of the Saint-Antoine Orchestra program has provided a unique opportunity to assess and improve the prevention and management of comorbidities in HIV patients. Also, this program aimed to improve professional practices.

[Imaging of thoracic pathology in patients with AIDS]. / Imagerie des pathologies thoraciques chez le patient VIH au stade sida.

The imaging features of infectious and non-infectious pathologies in HIV patients with AIDS (less than 200 CD4/mm3) are illustrated. Opportunistic infections, tumors and vascular pathologies have variable appearances based on the degree of immunosuppression and patient compliance with opportunistic infection prophylaxis. Because of advances in retroviral treatments and wider use of anti-infectious prophylaxis, thoracic pathologies in AIDS patients are less frequent but must nonetheless be recognized, and diagnosis should be suggested in patients with unknown serologic status.

The trapezius port: a novel approach for port access.

Placement of long-term central venous access in breast cancer patients who have undergone bilateral mastectomy presents a unique challenge. The standard anterior chest wall placement of the port may be compromised by factors such as a fresh surgical site, the possibility of postoperative radiation therapy, or the immediate reconstruction field. To avoid the potential for complications that impact the surgical field or subsequent therapy, we have developed a unique new technique for central venous port placement: the trapezius port. By placing the port in a subcutaneous pocket over the trapezius muscle, the risk of infection or cross-contamination of the surgical site is avoided.

Tumour-like inflammatory abdominal conditions in children.

The presence of a tumour, poor general condition, features of anaemia, increased erythrocyte sedimentation rates and imaging suggesting malignancy were the common features in 4 different tumour-like abdominal conditions that are extremely rare in childhood. These conditions included: extensive retroperitoneal tumour with rib involvement that turned out to be an inflammatory lesion caused by Actinomyces in a 12-year-old girl; multi-loculated tumour of the mesentery/ovary caused by mesenteric lymphadenopathy in the course of a Salmonella enteritidis infection in a 2.5-year-old girl; tumour of the VII - VIII hepatic segments that turned out to be the focus of granuloma in the course of lambliasis in a 5.5-year-old boy with a history of purulent neck lymphadenopathy and a final suspicion of immunocompromise; and a multi-loculated tumour of the small pelvis and inguinal area that turned out to be an abscess of the iliopsoas muscle in a 16-year-old boy. Apart from the imaging, the lesions required cytological examination of the material harvested by fine-needle biopsies (liver tumour) or histopathological investigations (retroperitoneal tumour, mesenteric/ovarian tumour, liver tumour and--on second surgery--the pelvic tumour) and/or bacteriological examination (all cases), serological examination (liver tumour and mesenteric/ovarian tumour), protozoal investigation (liver tumour), and measurement of AFP levels (mesenteric/ovarian tumour). Surgical treatment (retroperitoneal tumour, mesenteric/ovarian tumour and tumour of the small pelvis) and guided antibiotic therapy (all cases including 15 weeks of antibiotics in the first case) allowed complete recovery in 3 patients (actinomycosis, mesenteric lymphadenopathy, abscess of the iliopsoas muscle). Antibiotic and antiprotozoal therapy cured the granulomatous hepatitis; however this patient tended to develop severe right-sided pleural/pulmonary changes (the child was referred for further diagnosis with suspicion of immunocompromise).

Erectile function after open or endovascular abdominal aortic aneurysm repair.

Open abdominal aortic aneurysm repair has been reported to be associated with impairment of sexual function in men, most likely because of autonomic nerve injury and pelvic blood flow changes. Endovascular aneurysm repair does not involve dissection in the area of the iliac bifurcation and therefore may be associated with lower incidence of sexual dysfunction as compared to open repair. We conducted a retrospective study of males after open and endovascular abdominal aortic aneurysm repair to determine if there is a significant difference in the incidence of sexual dysfunction between the two procedures. A modified International Index of Erectile Function Questionnaire was used to access sexual function before and after aneurysm repair. The questionnaire was mailed to all male patients who underwent abdominal aortic aneurysm repair from January 1, 1999 to July 15, 2002. The questionnaire asked patients questions regarding their sexual function before and 3 months after the repair. Questionnaire scores for domains of sexual function (erectile function, orgasmic function, intercourse satisfaction, and overall satisfaction) as well as the total questionnaire score were analyzed. The chi-square and Wilcoxon's signed ranks test were used for statistical comparisons, with p < 0.05 considered significant. Logistic regression was used to examine association. Two hundred ninety-three questionnaires were mailed and 90 were returned completed. There was no difference for the total questionnaire score or the erectile function score before the procedure. Based on the questionnaire score, erectile function worsened after open AAA repair ( p = 0.002). Orgasmic function also deteriorated after open AAA repair ( p = 0.001). Endovascular repair was not accompanied by decreased erectile or orgasmic function ( p = 0.057 and p = 0.068, respectively). Impairment of erectile function was not associated with age, diabetes, or the number of patent hypogastric arteries after aneurysm repair, but there was a significant association between impaired erectile function and open aneurysm repair ( p = 0.036). Endovascular repair of abdominal aortic aneurysms is associated with significantly less impairment of erectile and orgasmic function than that with open repair. Preservation of sexual function after endovascular as compared to open repair should be among the factors considered when weighing treatment options for an abdominal aortic aneurysm in a sexually active male.

Reduced blood CD123+ (lymphoid) and CD11c+ (myeloid) dendritic cell numbers in primary HIV-1 infection.

Successful immunologic control of HIV infection is achieved only in rare individuals. Dendritic cells (DCs) are required for specific antigen presentation to naive T lymphocytes and for antiviral, type I interferon secretion. Two major blood DC populations are found: CD11c+ (myeloid) DCs, which secrete IL-12, and CD123+ (IL-3-receptor+) DCs (lymphoid), which secrete type I interferons in response to viral stimuli. The authors have previously found a decreased proportion of blood CD11c+ DCs in chronic HIV+ patients. In this study, 26 to 57 days after infection and before treatment, CD123+ and CD11c+ DC numbers were dramatically reduced in 13 HIV+ patients compared with 13 controls (P =.0002 and P =.001, respectively). After 6 to 12 months of highly active antiretroviral therapy, DC subpopulation average numbers remained low, but CD123+ DC numbers increased again in 5 of 13 patients. A strong correlation was found between this increase and CD4 T-cell count increase (P =.0009) and plasma viral load decrease (P =.009). Reduced DC numbers may participate in the functional impairment of HIV-specific CD4+ T cells and be responsible for the low type I interferon responsiveness already known in HIV infection. The restoration of DC numbers may be predictive of immune restoration and may be a goal for immunotherapy to enhance viral control in a larger proportion of patients.

Aortic arch (pseudo) aneurysm complicating cardiac catheterization.

The development of an infected aortic (pseudo)aneurysm which occurred after placement of a coronary artery stent is reported. Complications of cardiac catheterization and coronary artery stent placement are infrequent and this complication has not yet been reported in the literature.

Interruption of prophylaxis for major opportunistic infections in HIV-infected patients receiving triple combination antiretroviral therapy.

UNLABELLED: Interruption of prophylaxis for major opportunistic infections in HIV-infected patients receiving triple combination antiretroviral therapy. OBJECTIVE: To determine whether HIV-infected patients receiving highly active antiretroviral therapy (HAART) and recovering a CD4 cell number above 200x10(6)/l may safely discontinue primary and secondary prophylaxes for major opportunistic infections. DESIGN: Retrospective study of a single-center, prospectively constituted cohort of 223 patients receiving HAART with a protease inhibitor, of whom 137 received at least one prophylaxis. METHODS: Exhaustive informations on prophylaxis use, clinical and laboratory data were used to produce descriptive statistics on infectious events, duration of HIV infection, time on HAART, time to prophylaxis interruption, length of follow-up and biological values at relevant time points. RESULTS: Fifty-one patients with a history of severe immunodepression (median CD4 nadir: 62x10(6)/l), including 16 patients with CDC stage C infection, discontinued at least one prophylaxis. Primary or secondary P. carinii pneumonia prophylaxis was discontinued in 43 patients: 1 first episode of PCP occurred after 2 months but no other episode was recorded after a median follow-up of 16 months. Toxoplasmosis primary or secondary prophylaxis, secondary cytomegalovirus prophylaxis and primary or secondary M. avium complex prophylaxes were discontinued in respectively 37, 5 and 5 patients, and no event was recorded after respective follow-ups of 16, 7 and 15 months. Nine secondary and 2 primary acyclovir prophylaxes were discontinued, and two events were observed after 1 and 19 months; no other event was noted after a follow-up of 22 months. CONCLUSION: Prophylaxis for opportunistic infections could be safely interrupted in most of these severely immunodeficient patients recovering a CD4 cell count above 200x10(6)/l on HAART. This confirms the efficiency of immune restoration and is beneficial to patients but, since 3 infectious events were recorded, caution should be taken before making a decision based on immunological and virological considerations.

Is routine roentgenography needed after closed tube thoracostomy removal?

BACKGROUND: Efficacy of chest radiograph protocol after tube thoracostomy tube (CT) removal. METHODS: Retrospective review (July of 1995 to July of 1996) of 141 patients with CT followed throughout their hospitalization. Excluded patients died (23 patients) or had thoracotomy (13 patients) before CT removal. RESULTS: A total of 105 patients had 113 CT removed (mean age, 36.9 years; Injury Severity Score = 23.4; CT duration, 5.0 days). Protocol chest radiographs were performed on average at 7.9 and 22.1 hours. Recurrent pneumothorax (RHPTX = new interpleural air) occurring in 12 patients (11%) and persistent pneumothorax (PHPTX = same volume of interpleural air) occurring in 13 patients (12%) caused no clinical problems and were treated without tube replacement. Three patients had symptoms after removal; none had RHPTX. Two patients had clinical signs; one reaccumulated a hemothorax requiring CT replacement, the other improved without replacement. CONCLUSIONS: Clinically significant RHPTX/PHPTX after CT removal is infrequent. Signs not symptoms detect CT removal complications. At our institution, chest radiographs are obtained in a delayed manner from protocol and offer no benefit over clinical assessment.

[Edward Wilhelm Drescher--the founder of pediatric surgery in West Pomerania]. / Edward Wilhelm Drescher--twórca chirurgii dzieciecej na Pomorzu Zachodnim.

Professor Edward Wilhelm Drescher--an eminent Polish pediatric surgeon and pioneer of this specialization in West Pomerania--was born in 1912 in Bilgoraj. His young years he spent in his parents familial town Kalisz, where he attended a very famous college--State Humanistic Grammar-School. In 1937 he graduated from Faculty of Medicine at the Warsaw University. Next year he started his career as a surgeon in the Surgery at Orthopedic Ward of Pediatric Clinic in Warsaw, which was directed by prof. Jan Kossakowski--excellent pediatric surgeon and artist. During the September Campaign he took part in the battle of Bzura and in the defense of Polish capital as the physician in the 25th Regiment of Artillery. In 1940 he joined Polish underground army--AK. In 1944, when the Warsaw Uprising broke out, he was the Commander of the insurgent hospital--Poznanska 11. It was a very well arranged and headed hospital, which admitted about eight hundred wounded soldiers and civilians. After the war for two years he lived in Sopot, where he organized and directed the Surgery Hospital and the Town Outpatients' Department. In 1947 he moved to Szczecin, where he arranged the first ward of pediatric surgery in West Pomerania (in Polish Red Cross hospital). Ten years later he was nominated the head of the Clinic of Pediatric Surgery in the Pomeranian Medical Academy in Szczecin. For many years Prof. Drescher was provincial and regional consultant. He helped to organize a few pediatric surgery wards in Pomerania (Koszalin, Gorzów Wlkp., Slupsk). He died in 1977 in Warsaw. Prof. Drescher published almost 80 scientific papers including two medical books. Traumatology of children and the newborn surgery became his principal area of interest. He was the author of Code of the Ethical and Moral Procedure of the Polish Medical Society. For almost twenty years he was co-author the Annales of Pomeranian Medical Academy. He was a co-founder, next was a president of the Polish Association of Pediatric Surgeons and next its honorary Member. Professor Drescher was well-known as a man of great humanist, an excellent teacher and surgeon with rich personality, getting easily into contact with every man, especially children.

Mitochondrial activity after cold preservation of pancreatic islet cells treated with pefloxacin (PFX).

Mitochondrial energetic and oxidative dysfunctions caused by free radical production trigger release of proinflammatory cytokines involved in organ rejection. The aim of this study was to investigate the role of a fluoroquinolone drug, pefloxacin (PFX) and those of various cold preservation solutions on pancreatic beta cell viability. Our data clearly demonstrate that islet cell viability, as determined by glucose-stimulated insulin secretion, is directly correlated with reduced expression of microsomal cytochrome P-450IIIA. Moreover, IL-2, a known mediator of apoptosis was found to be downregulated, whereas TNF-alpha had been upregulated for the first 18 hours after pefloxacin administration. These results demonstrate that pefloxacin downregulates the expression of cytochrome P-450IIIA isozyme and regulates the production of TNF-alpha and IL-2. Thus, we postulate that the presence of pefloxacin in the pancreatic islet cells before organ preservation facilitates increased cell viability.