Sex disparities in the utilization of nurse-assisted peritoneal dialysis: a mediation analysis using data from the REIN registry.

Background: This study was carried out to evaluate the association between patient sex and the proportion of nurse-assisted peritoneal dialysis (PD) at dialysis initiation and to explore whether sex disparities in nurse-assisted PD utilization was explained by predialysis care and/or by social deprivation using mediation analysis. Methods: This was a retrospective study using data from the Renal Epidemiology and Information Network (REIN) registry linked to the French National Healthcare Database (SNDS) of incident patients between 1 January 2017 and 30 June 2018. A regression logistic was used for statistical analysis. A mediation analysis explored the direct effect of sex on nurse-assisted PD proportion and the indirect effect through the European Deprivation Index (EDI), and the number of general practitioner (GP) and nephrologist visits before dialysis initiation. Results: Among 1706 patients on PD, there were 637 women (37.3%) and 1069 men (62.7%). Nurse-assisted PD proportion was 332/610 (54.4%) for women vs 464/1036 (44.8%) for men. In the multivariable analysis women were more likely to be treated by nurse-assisted PD {odds ratio (OR) 1.92 [95% confidence interval (CI) 1.46-2.52]}. Nurse-assisted PD was associated with the median number of GP visits [OR 1.44 (95% CI 1.11-1.86)] and with the median number of nephrologist visits [OR 0.59 (95% CI 0.46-0.76)]. The mediation analysis showed a direct effect of sex on nurse-assisted PD [OR 1.90 (95% CI 1.80-2.01)] and an indirect effect through the median number of GP visits [OR 1.05 (95% CI 1.04-1.06], the median number of nephrologist visits [OR 1.02 (95% CI 1.02-1.03)] and quintile 5 of the EDI [OR 1.03 (95% CI 1.02-1.03)]. Conclusion: Women were more frequently treated by nurse-assisted PD than men. Differences between women and men in predialysis care and social deprivation could explain the greater utilization of nurse-assisted PD among women.

Difficult-to-treat axial spondyloarthritis is associated with psoriasis, peripheral involvement and comorbidities: results of an observational nationwide study.

OBJECTIVES: To determine the cumulative incidence and identify the factors associated with difficult-to-treat axial spondyloarthritis (D2T-axSpA) in French patients newly benefiting from the French 'long-term illness' (LTI) social security scheme for axial spondyloarthritis (axSpA). METHODS: This national cohort study was based on the French National Medico-Administrative Database, SNDS, which contains data on hospitalisation, LTI and outpatient care consumption. All French patients newly receiving LTI benefits for ankylosing spondylitis (AS) between 2010 and 2013 were included in the study. In France, LTI is required to access biological/targeted synthetic DMARDs (b/tsDMARDs). The follow-up period ended on 31 December 2018. So-called D2T-axSpA was defined as the failure of three b/tsDMARDs or of two b/tsDMARDs with different modes of action. Comorbidities and extra-musculoskeletal manifestations were identified using previously described algorithms. Characteristics were compared between patients with D2T-axSpA and patients with non-D2T-axSpA who had received at least one b/tsDMARD with bivariate and multivariate analysis using logistic regression. Incidence rates of major cardiovascular event (MACE) and death were compared using competitive risk analysis. RESULTS: 22 932 patients were included. 10 798 (47.08%) patients received at least one bDMARD. None received tsDMARD. During follow-up, 2115 patients were classified as having D2T-axSpA, representing 19.59% of patients who received at least one bDMARD. In multivariate analysis, D2T-axSpA was significantly associated with female gender, peripheral involvement, psoriasis, hypertension and depression (p<0.001 for each case). There was no difference in the incidence of MACE (p=0.92) or death (p=0.87). CONCLUSION: D2T-axSpA affects one in five patients exposed to bDMARDs in this national cohort. D2T-axSpA is more common in women and patients with peripheral involvement and/or comorbidities.

Locomotor Strategy to Perform 6-Minute Walk Test in People with Multiple Sclerosis: A Prospective Observational Study.

Two-thirds of people with Multiple Sclerosis (PwMS) have walking disabilities. Considering the literature, prolonged tests, such as the 6 min walk test, better reflect their everyday life walking capacities and endurance. However, in most studies, only the distance traveled during the 6MWT was measured. This study aims to analyze spatio-temporal (ST) walking patterns of PwMS and healthy people in the 6MWT. Participants performed a 6MWT with measures of five ST variables during three 1 min intervals (initial: 0'-1', middle: 2'30″-3'30″, end: 5'-6') of the 6MWT, using the GAITRite system. Forty-five PwMS and 24 healthy people were included. We observed in PwMS significant changes between initial and final intervals for all ST parameters, whereas healthy people had a rebound pattern but the changes between intervals were rather negligible. Moreover, ST variables' changes were superior to the standard measurement error only for PwMS between initial and final intervals for all ST parameters. This result suggests that the modification in PwMS' walking pattern is effectively due to their walking ability and not to a measurement, and suggests that PwMS could not manage their walking efficiently compared to healthy people, who could maintain their rhythm throughout the 6MWT. Further studies are needed to detect these patterns changes in the early evolution of the disease, identify clinical determinants involved in PwMS' walking pattern, and investigate whether interventions can positively impact this pattern.

Impact of NSAIDs on 8-year cumulative incidence of major cardiovascular events in patients with ankylosing spondylitis: a nationwide study.

OBJECTIVES: The objectives of this study were to describe the incidence of major adverse cardiovascular events (MACEs) in French patients newly benefiting from the French Long-term Illness scheme (LTI) for AS and to evaluate the effect of various treatments on the risk of MACE occurrence. METHODS: This national cohort study was based on the French national medico-administrative database SNDS containing data on hospitalization, the LTI, and outpatient care consumption. All French patients newly receiving LTI benefits for AS from 2010 to 2013 were included. The final follow-up date was 31 December 2018. The occurrences of MACEs [stroke and myocardial infarction (MI)] and comorbidities were identified from algorithms previously described in the literature. Competitive risk analysis using propensity score and inverse weighting was performed to calculate cumulative incidence functions and to determine subhazard ratios (SHRs) for the various treatments of interest. RESULTS: Between 2010 and 2013, 22 929 patients were included [mean age 43.0 (s.d. 13.9) years, 44.9% mal]. The 8-year cumulative incidences of MACE, stroke, and MI were 1.81% (1.61-2.05), 0.97% (0.83-1.14), and 0.85% (0.71-1.04), respectively. NSAIDs [SHR: 0.39 (0.32-0.50), P < 0.001] and anti-TNF [SHR 0.61 (0.46-0.80), P < 0.001], but not anti-IL17 [2.10 (0.79-5.57)] were associated with a lower risk of MACE occurrence. CONCLUSION: MACE incidence rates at 8 years are low in patients newly benefiting from LTI for AS. Our results support the hypothesis of a protective role of NSAIDs and anti-TNF in cardiovascular risk in these patients.

Interaction between science advice and policymaking in time of COVID-19: a French perspective.

BACKGROUND: In the coronavirus disease 2019 (COVID-19) context, many governments relied on scientific consultative bodies to advise their policy, but their contribution remains poorly documented. This article aims to fill this gap by reviewing the role played by the French High Council for Public Health (HCSP) in the French government's response to COVID-19. METHODS: We studied the time distribution of the COVID-19 guidelines produced by the HCSP until November 2020, computed their delay of production and analyzed the thematic areas they cover. To assess their use by the authorities, we looked for references to these guidelines in the regulatory texts, protocols and press communicates issued by national and local authorities until January 2021. RESULTS: The HCSP was strongly demanded with 102 guidelines produced following 97 official requests and two self-referrals. Most of them (N = 43) concerned protective measures to constrain the infection, while health inequalities and mental health were poorly addressed. Timing was very constraint as half of the guidelines were requested within 4 days. In total, 73% of the guidelines were used by policymakers to implement new obligations or within communication toward the public at national and local levels. CONCLUSIONS: This article informs on the HCSP's contribution during the crisis and stresses the difficulties it encountered to provide quality recommendations in very short times. It prompts governments to enlarge the competencies of their advisory boards and to consider the multidimensional aspects of health in policy design.

To what extent do age, stage and treatment influence survival after invasive cervical cancer: a French population-based study.

PURPOSE: In an attempt to understand why cervical cancer (CC) survival is decreasing with diagnosis period among older women in France, this study aimed to estimate the effects of main prognostic factors on net survival in CC according to age. METHODS: French cancer registries databases were used to retrospectively analyze women diagnosed with CC in 2011-2012. Net survival was estimated with the Pohar-Perme method and prognostic factors (socio-demographic, clinical variables, stage at diagnosis, therapeutic management) were analyzed with Lambert and Royston's flexible parametric model. RESULTS: One thousand one hundred fifty three women with CC were identified. 30.4% were < 45, 41.4% 45-64, and 28.3% ≥ 65 years. Older women were diagnosed at a more advanced stage than younger women: 54.8% regional (FIGO IB2-IVA), 33.0% distant (IVB) in women ≥ 65 years vs 33.7% and 8.0%, respectively in women < 45 years. Half of women with regional stage of CC received recommended treatment; this rate decreased with increasing age (< 45: 66.1%, 45-64: 62.7%, ≥ 65: 29.2%). Older age was significantly associated with increased risk of death: hazard ratio 1.89 for age ≥ 65, as were regional stage (2.81), distant stage (15.99), and not receiving recommended treatment (2.26). CONCLUSION: Older women with CC diagnosed at advanced stage who do not receive standard of care are at markedly increased risk of death. Special attention to the management of older women is warranted in France, not only to diagnose cancer at an earlier stage (via gynecological follow-up in these menopaused women who remain at risk of CC), but also to ensure they receive standard of care, taking into account their overall state of health.

Evaluation of Prolonged Walking in Persons with Multiple Sclerosis: Reliability of the Spatio-Temporal Walking Variables during the 6-Minute Walk Test.

BACKGROUND: Walking disorders represent the most disabling condition in persons with Multiple Sclerosis (PwMS). Several studies showed good reliability of the 6-min walk test (6MWT) (i.e., especially distance traveled), but little is known about the reliability of the Spatio-temporal (ST) variables in the 6MWT. OBJECTIVE: To evaluate the test-retest reliability of ST variables and perceived exertion during the 6MWT in PwMS and comparable healthy persons. METHODS: We explored three 1-min intervals (initial: 0'-1', middle: 2'30″-3'30″, end: 5'-6') of the 6MWT. Six ST variables and perceived exertion were measured (respectively, using the GAITRite system and the Borg Scale). These measurements were performed twice, 1 week apart. The test-retest effects were assessed using the intraclass correlation coefficient (ICC) or the weighted kappa. RESULTS: Forty-five PwMS and 24 healthy persons were included. The test-retest reliability of ST variables values was good-to-excellent for PwMS (ICC range: 0.858-0.919) and moderate-to-excellent for healthy persons (ICC range: 0.569-0.946). The test-retest reliability values of perceived exertion were fair for PwMS (weighted kappa range: 0.279-0.376) and substantial for healthy persons (weighted kappa range: 0.734-0.788). CONCLUSION: The measurement of ST variables during these 6MWT intervals is reliable and applicable in clinical practice and research to adapt rehabilitation care in PwMS.

Visceral adiposity in patients with psoriatic arthritis and psoriasis alone and its relationship with metabolic and cardiovascular risk.

BACKGROUND: Fat mass distribution, especially in the abdominal visceral region, has been rarely evaluated in patients with PsA or psoriasis (PsO). METHODS: Patients with PsA and patients with PsO alone were evaluated and compared with control subjects (1:1 ratio in each patient group) matched for age, sex and BMI category. Body composition and fat distribution (android and visceral fat) were evaluated by DXA. Anthropometric measurements, disease activity and the systematic coronary risk evaluation (SCORE) cardiovascular risk were assessed. Metabolic parameters (insulin, homeostasis model assessment for insulin resistance), serum adipokines [total and high-molecular-weight adiponectin, leptin, resistin and retinol-binding protein-4 (RBP4)] were measured. RESULTS: Data for 52 patients with PsA and 52 patients with PsO and their respective paired controls were analysed. Android fat and visceral fat were found to be significantly higher in patients with PsO compared with their controls, while these measurements did not differ between patients with PsA and their controls. By multivariate analysis, after adjusting for age, sex and BMI, visceral fat was higher in PsO patients compared with PsA patients (P = 0.0004) and the whole group of controls (P = 0.0013). Insulin levels and HOMA-IR were increased in both PsA and PsO groups. High-molecular-weight/total adiponectin ratio was decreased in patients with PsO. RBP4 was significantly higher in both PsA and PsO patients. In patients with PsO, visceral fat strongly correlated with SCORE (r = 0.61). CONCLUSION: Visceral fat accumulates more in PsO alone than in PsA. Visceral adiposity may be a more pressing concern in PsO relative to PsA. TRIAL REGISTRATION: The ADIPSO study (Évaluation du tissu ADIpeux et des adipokines dans le PSOriasis et le rhumatisme psoriasique et analyse de ses relations avec le risque cardiovasculaire) is a case-control study conducted in Besançon, France, and is registered on ClinicalTrials.gov under the number NCT02849795.

Fine-scale geographic variations of rates of renal replacement therapy in northeastern France: Association with the socioeconomic context and accessibility to care.

BACKGROUND: The strong geographic variations in the incidence rates of renal replacement therapy (RRT) for end-stage renal disease are not solely related to variations in the population's needs, such as the prevalence of diabetes or the deprivation level. Inequitable geographic access to health services has been involved in different countries but never in France, a country with a generous supply of health services and where the effect of the variability of medical practices was highlighted in an analysis conducted at the geographic scale of districts. Our ecological study, performed at the finer scale of townships in a French area of 8,370,616 inhabitants, investigated the association between RRT incidence rates, socioeconomic environment and geographic accessibility to healthcare while adjusting for morbidity level and medical practice patterns. METHODS: Using data from the Renal Epidemiology and Information Network registry, we estimated age-adjusted RRT incidence rates during 2010-2014 for the 282 townships of the area. A hierarchical Bayesian Poisson model was used to examine the association between incidence rates and 18 contextual variables describing population health status, socioeconomic level and health services characteristics. Relative risks (RRs) and 95% credible intervals (95% CrIs) for each variable were estimated for a 1-SD increase in incidence rate. RESULTS: During 2010-2014, 6,835 new patients ≥18 years old (4231 men, 2604 women) living in the study area started RRT; the RRT incidence rates by townships ranged from 21 to 499 per million inhabitants. In multivariate analysis, rates were related to the prevalence of diabetes [RR (95% CrI): 1.05 (1.04-1.11)], the median estimated glomerular filtration rate at dialysis initiation [1.14 (1.08-1.20)], and the proportion of incident patients ≥ 85 years old [1.08 (1.03-1.14)]. After adjusting for these factors, rates in townships increased with increasing French deprivation index [1.05 (1.01-1.08)] and decreased with increasing mean travel time to reach the closest nephrologist [0.92 (0.89-0.95]). CONCLUSION: These data confirm the influence of deprivation level, the prevalence of diabetes and medical practices on RRT incidence rates across a large French area. For the first time, an association was found with the distance to nephrology services. These data suggest possible inequitable geographic access to RRT within the French health system.

[Who are these patients on dialysis and not on the kidney transplant waiting list?] / Qui sont ces patients en dialyse non inscrits sur liste d'attente de greffe rénale ?

Access to kidney transplants for patients with end-stage chronic renal disease is a major challenge in France. Registration on the transplant waiting list is a mandatory step to be able to access this technique. The Haute Autorité de santé (HAS) updated, in 2015, the contraindications to access this list. In this context, we wanted to make an inventory of the reasons for non-registration on the renal transplant waiting list in patients on dialysis for at least a year, aged less than 80 years, in France. All patients included in the Epidemiology and Nephrology Information Register (REIN), who were supposed to have their annual monitoring point from August 1 to November 30, 2016 meeting the criteria, were included and a dedicated questionnaire was completed by their dialysis center. Thus, 3172 patients were analyzed: 2302 (73%) had a medical contraindication to transplant, most often (33%) vascular, 458 (14%) refused to be registered, with proportionately more women in this category, and finally in 412 patients (13%), there was no reason given in our questionnaire. However, for 65% of patients in the latter category, an assessment for registration had started. There were therefore, in our cohort, only 144 patients (4.5%) without explanation for the non-registration. This national study is the first to give a view of the reasons for non-registration on the renal transplant list in France. Unsurprisingly, medical contraindication is the primary reason in this population of chronic patients. The high refusal rate should be emphasized and analyzed more precisely, in particular with the patient's point of view. And finally, very few patients have no informed reason or current assessment.

A pragmatic non-invasive assessment of liver fibrosis in patients with psoriasis, rheumatoid arthritis or Crohn's disease receiving methotrexate therapy.

BACKGROUND AND AIMS: The reported hepatotoxicity of methotrexate underlines the need for a repeated non-invasive and reliable evaluation of liver fibrosis. We estimated, using a non-invasive strategy, the prevalence of significant liver fibrosis in patients treated by methotrexate and the predictors of significant fibrosis (fibrosis≥F2). METHODS: Fibrosis was prospectively evaluated using 9 non-invasive tests in consecutive patients with psoriasis, rheumatoid arthritis, or Crohn's disease. Significant fibrosis was assessed without liver biopsy by defining a "specific method" (result given by the majority of the tests) and a "sensitive method" (at least one test indicating a stage≥F2). RESULTS: One hundred and thirty-one patients (66 Psoriasis, 40 rheumatoid arthritis, and 25 Crohn's disease) were enrolled, including 83 receiving methotrexate. Seven tests were performed on average per patient, with a complete concordance in 75% of cases. Fibroscan® was interpretable in only 61% of patients. The best performances (AUROC>0.9) for predicting significant fibrosis were obtained by tests dedicated to steatohepatitis (FibroMeter NAFLD, NFS and FPI). The prevalence of fibrosis≥F2 according to the "specific" or the "sensitive" assessment of fibrosis was 10% and 28%, respectively. Methotrexate exposure did not influence the fibrosis stage. Factors independently associated with significant fibrosis according our "sensitive method" were age, male gender, and metabolic syndrome. CONCLUSION: We provided a non-invasive approach for identifying liver fibrosis≥F2 by using 8 biochemical tests and Fibroscan®. In this population, the risk of significant fibrosis was related to age, male gender, and presence of metabolic syndrome, but was not influenced by methotrexate.

Let us not underestimate the long-term risk of SPLC after surgical resection of NSCLC.

OBJECTIVES: Several studies have reported that patients operated on for non-small cell lung cancer (NSCLC) are at high risk of second primary lung cancer (SPLC). However, widely varying estimates of this risk have been reported, with very few studies taking into account that these patients are at particularly high competing risk of death, due to recurrence of the initial disease and to comorbidities. Risk factor evaluation over time has significant repercussions on the post-surgery surveillance strategy offered for NSCLC. This study primarily sought to measure the risk of SPLC in a long-term follow-up series, using statistical methods considering competing risks of death. MATERIALS AND METHODS: The cumulative SPLC risk was estimated using the cumulative incidence of patients with completely resected Stage I-III NSCLC diagnosed between 2002 and 2015 based on the Doubs and Belfort cancer registry (France). A proportional sub-distribution hazard model (sdRH) was used to investigate factors associated with SPLC risk in the presence of competing risks. RESULTS: Among the 522 patients, adenocarcinoma and Stage I or II disease accounted for 52.3% and 75.7% of patients, respectively. Overall, 84 patients developed SPLC (16.1%). The cumulative risk of SPLC was 20.2% at 10 years post-surgery (95% confidence interval [CI]: 15.3-23.2), and 25.2% (CI: 19.4-31.3) at 14 years post-surgery. On multivariate analysis, the SPLC risk was significantly higher in patients with postoperative thoracic radiotherapy (sdRH 2.79; 95% CI: 1.41-5.52; p = 0.003). CONCLUSION: This study using appropriate statistical methods to consider competing risks showed that after complete NSCLC resection, the cumulative incidence function of SPLC was high, with patients receiving postoperative thoracic radiotherapy at higher risk. These data support the need for life-long follow-up of patients who undergo NSCLC surgery, with the objective of screening for SPLC.

2017 Annual Report Digest of the Renal Epidemiology Information Network (REIN) registry.

The French Renal Epidemiology and Information Network (REIN) registry started in 2002 with the goal to provide a tool to evaluate renal replacement therapy (RRT) practices and outcomes, to provide data for research and to support public health decisions related to end-stage renal disease ESRD. This summary presents the incidence and prevalence of RRT including kidney transplantation and wait-listing activity in 2017, and patients' survival and trends over 5 years. In 2017, 11 543 patients started RRT for ESRD, that is, incidence of 172 pmp. Between 2012 and 2017, the incidence of RRT increased by 1% per year [CI 95% (0.0; +2.0)]. On 31 December 2017, 87 275 patients were receiving RRT, that is, prevalence of 1294 pmp, 55% on dialysis, 45% with a functioning transplant. In 2017, 3782 kidney transplantations have been performed including 16% from a living donor, 13% being retransplantations and 15% pre-emptive transplantations. The median time on the waiting list was 19.7 months when only taking into account active waiting periods on the list. In 2017, 5280 new patients were registered on the renal transplant waiting list (i.e. 78.7 pmp). The number of patients considered as 'inactive' represented 45% of the patients on the list.

Accuracy of calprotectin using the Quantum Blue Reader for the diagnosis of spontaneous bacterial peritonitis in liver cirrhosis.

AIM: We aimed to evaluate the accuracy of the dosage of calprotectin in ascitic fluid (AF) using the Quantum Blue assay, for the prompt diagnosis of spontaneous bacterial peritonitis (SBP). METHODS: We prospectively collected 236 AF samples from 119 cirrhotic patients hospitalized in two French centers between May 2016 and May 2017. Bloody and chylous/cloudy AF, and secondary peritonitis were excluded. SBP was diagnosed if neutrophils in AF were >250/mm3 using standard cytology. The Quantum Blue Reader selectively measured the calprotectin antigen (MRP8/14) in 12 min within the measurable range from 0.18 to 1.80 µg/mL; values outside this range were registered as 0.17 and 1.81 µg/mL. RESULTS: A total of 36 AF were considered as SBP (15.2%). SBP had higher median levels of calprotectin than non-SBP (1.81 vs. 0.25 µg/mL, P < 0.001). Calprotectin levels were positively correlated with neutrophils in AF (r = 0.57, P < 0.001) and C-reactive protein (r = 0.43, P < 0.001), but not with the Child-Pugh and Model for End-Stage Liver Disease scores. The optimal threshold of calprotectin to diagnose SBP was set at 1.51 µg/mL (80th percentile of calprotectin), yielding sensitivity, specificity, and positive and negative predictive values of 86.1%, 92.0%, 65.9%, and 97.3%, respectively. Only one asymptomatic patient with SBP had a low calprotectin level, but a high serum C-reactive protein level that strongly suggested an ongoing infection. We also showed that intraclass correlation coefficients for inter- and intra-observer agreement were excellent, with 0.95 and 0.89, respectively. CONCLUSIONS: The dosage of calprotectin in AF using the Quantum Blue assay is a rapid and reliable method of ruling out SBP in hospitalized cirrhotic patients.

Impact of Cytomegalovirus Infection on the Outcome of Patients With Cirrhosis: A Preliminary Study.

GOALS: The aims of this study were to evaluate whether cytomegalovirus (CMV) infection is associated with hepatocellular carcinoma (HCC) and liver-related mortality in cirrhotic patients. BACKGROUND: In cirrhotic patients, the determinants of HCC and liver-related death are imperfectly known. CMV infection, by its prooncogenic and proinflammatory properties, may favor both the development of HCC and deleterious systemic inflammation. STUDY: In the 1178 patients included between June 2008 and December 2012 in the CIrrhose et Risque de Carcinome Hépatocellulaire dans le grand-Est (CIRCE) study, a French multicenter case-control study designed to identify risk factors of HCC among cirrhotic patients, we identified 432 patients with interpretable CMV serological status at baseline. They included 159 cases with HCC and 273 controls. We measured factors associated with HCC at baseline and subsequent HCC in controls, and predictors of overall and liver-related death in the whole study population. RESULTS: During a median follow-up of 31 months, 25 cases of HCC developed in controls, and 209 deaths (163 liver-related) were recorded. There were 247 (57.2%) CMV-seropositive patients. CMV seropositivity was not associated with more frequent HCC at baseline or during follow-up, but among CMV-positive patients with HCC, the proportion of multinodular, infiltrative, or metastatic tumors at diagnosis was higher (73.8% vs. 57.3%; P=0.029), inducing higher mortality (74% vs. 52% at 3 years; P=0.004). By Cox-regression adjusted for age, gender, Model for End-stage Liver Disease (MELD) score, HCC at baseline, and diabetes, CMV seropositivity independently predicted all-cause (hazard ratio=1.45; 95% confidence interval, 1.08-1.94; P=0.013) and liver-related mortality (hazard ratio=1.56; 95% confidence interval, 1.04-2.30; P=0.031). CONCLUSIONS: In this preliminary study, CMV-seropositive cirrhotic patients were at higher risk of liver-related death caused by more aggressive HCCs or severe cirrhosis complications. These findings warrant confirmation.

Factors related to the outcome of prophylactic platelet transfusions in patients with hematologic malignancies: an observational study.

BACKGROUND: A better knowledge of the connections between platelet concentrate (PC) characteristics and transfusion outcomes in day-to-day practice would help improve the selection process of the most appropriate PC. STUDY DESIGN AND METHODS: In this study of prophylactic platelet transfusions in patients with hematologic malignancies between 2002 and 2012, outcome criteria were corrected count increments (CCIs) and platelet transfusion intervals (TIs, in days). Studied characteristics were ABO matching status, platelet source, dose, storage duration, irradiation, washing, and transfusion sequence number (TSN). The analysis consisted of multivariable linear mixed-effects models with adjustments for patient diagnosis, sex, and type of treatment. RESULTS: Overall, 869 patients and 6662 platelet transfusions were analyzed. For each day after the second day of storage, the CCI and TI decreased by 0.88 and 0.06 day, respectively. Compared to ABO-identical, transfusion with major ABO-incompatible PCs decreased the CCI and TI by 0.79 and 0.21 day, respectively. Platelet washing reduced the CCI and TI by 2.28 and 0.24 day, respectively. There was no significant association between platelet source or irradiation and CCI or TI. TI increased as the platelet dose per kg increased. Both CCI and TI decreased as the TSN increased. CONCLUSION: Transfusion outcomes were significantly related to several PC-related factors. Associations for ABO matching status and storage duration were stronger than previously reported. Taking into account such factors when selecting a PC for transfusion could be beneficial to the recipient.

Health care delivery for patients with rare diseases / Organisation de l'offre de soins pour les patients atteints de maladies rares

Health care delivery for patients with rare diseases. Currently more than 7000 rare diseases have been identified, that should affect more than 3 million people in France. Reducing frequent delay in diagnosis and improving coordination of care are public health priorities addressed by the two French National Plans for Rare Diseases. Specialized care offer is made of 23 healthcare networks for rare diseases, 131 centres of expertise and 501 skilled satellite centres. Additional efforts are required in order to enhance patient information, to build an information strategy for professionals, to share best practices and to improve reimbursement of health expenditure.

Organisation de l'offre de soin pour les patients atteints de maladies rares. À ce jour plus de 7 000 maladies rares ont été répertoriées, qui concerneraient en France environ 3 millions de patients. La réduction de l'errance diagnostique fréquente chez ces patients et l'amélioration de l'organisation des prises en charge constituent des priorités de santé publique, prises en compte par deux Plans nationaux maladies rares successifs. L'offre de soins française actuelle comporte 23 filières de santé maladies rares, 131 centres de référence et 501 centres de compétences. Des efforts restent à accomplir pour renforcer l'information du public, construire une stratégie d'information des professionnels, homogénéiser les pratiques, et améliorer le remboursement des soins.

Blood products use in France: a nationwide cross-sectional survey.

BACKGROUND: Blood products use has increased in France between 2000 and 2011. To understand the reasons for this increase, data about transfused patients and transfusion practices needed to be updated. STUDY DESIGN AND METHODS: A nationwide cross-sectional survey was performed with health care establishments. Diagnoses and indication for the transfusion, pretransfusion laboratory results, and blood products used were collected during a randomly selected 24-hour period in 2011. All patients who received at least one blood product delivered on the survey day were included. RESULTS: A total of 10,794 blood products were requested for 4720 patients: 8688 red blood cell (RBC) units, 842 platelet (PLT) concentrates, and 1264 fresh-frozen plasma (FFP) units. Hematologic and cancer pathologies included 46% of transfused patients, 34% of the patients had transfusions in a surgical context, and 32.4% of transfused patients were receiving medication with an impact on transfusion. Nearly half of RBC transfusions were performed with hemoglobin levels of less than 8 g/dL. PLT transfusions for prophylactic indication were prescribed with PLT counts of less than 20 × 109 and 50 × 109 /L in 56.9 and 86.6% of patients, respectively. RBCs and PLTs transfusion practices were in agreement with national guidelines. FFP units were involved in 8.0% of all prescriptions. Among these, 57.4% were requested in the context of an acute hemorrhage and 8.4% for plasma exchange. The median of FFP use (n = 2) in a nonsurgical context, excluding plasma exchange, suggests an insufficient dosing of FFP. CONCLUSION: Except for insufficient FFP dosing per patient and limitations on assessment of indications for prescribing, transfusion practices were in agreement with national guidelines.

Propofol-remifentanil anesthesia for upper airway endoscopy in spontaneous breathing patients: the ENDOTANIL Randomized Trial.

BACKGROUND: The ENDOTANIL Trial aimed at comparing an association of target-controlled infusion (TCI) of remifentanil and propofol to TCI of propofol alone on the clinical conditions during pan endoscopy for assessment of the upper airway (pan endoscopy) performed under tubeless general anesthesia. METHODS: This double-blind, single center, parallel, randomized, placebo-controlled trial was conducted in a French tertiary level of care, from June 2009 to February 2013. Patients scheduled for elective pan endoscopy were anesthetized using propofol TCI combined to either remifentanil TCI (effect-site concentration=1.5 ng.mL-1; remifentanil group) or placebo (control group). The main outcome measure was the percentage of clinically acceptable conditions for pan endoscopy, using a 5-criteria score (ease of laryngoscopy, position and movements of the vocal cords, cough and movements of the limbs to stimulation). The secondary outcomes were hemodynamic and respiratory safety. RESULTS: In this study 218 patients (mean±SD age 60 [10] yrs) were included. Clinically acceptable conditions were observed in 68% and 64% of the patients included in Remifentanil and Control group, respectively (P=0.39). None of the 5 parameters of the pan endoscopy score was significantly different between the 2 groups. Hemodynamic alterations were significantly lower in the Remifentanil as compared to the control group. Incidence of hypoxemia or need for rescue mechanical ventilation did not significantly differ between the 2 groups. CONCLUSIONS: The adjunction of remifentanil to propofol TCI, at a dose that maintain spontaneous breathing, did not improve the conditions for pan endoscopy, but attenuates the hemodynamic response induced by upper airway stimulation.

Effect of storage time and donor sex of transfused red blood cells on 1-year survival in patients undergoing cardiac surgery: an observational study.

BACKGROUND: Red blood cell (RBC) storage lesions and RBCs from females transfused into male recipients may have adverse effects on transfusion recipients' survival. We hypothesized that the effect of donor sex and the effect of age of blood on mortality would be most apparent in cardiac surgery patients. STUDY DESIGN AND METHODS: Using data from French Blood Services and two university hospitals, we conducted a retrospective cohort study on cardiac surgery patients whose first transfusion occurred between 2007 and 2011. The age of blood and donor sex effects on 1-year survival were studied using Cox regression modeling, with time-dependent stratification on the number of RBCs and adjustments for the type of surgery and other products transfused. RESULTS: Among the 2715 cardiac surgery patients, 85.1% were alive after 1 year. Age of blood and donor sex were associated with survival before adjustments (p < 0.0001). However, the adjusted hazard ratios (HRs) for patients transfused with blood stored for 29 days or more versus 14 days or less were 0.97 (95% confidence interval [95% CI], 0.69-1.35; p = 0.98) and 1.22 (95% CI, 0.81-1.82) for patients who received only sex-mismatched RBCs versus all matched units (p = 0.27). For males transfused solely with female RBCs, the HR was 0.96 (95% CI, 0.57-1.61; p = 0.69); in females transfused only with male RBCs, it was 2.03 (95% CI, 0.87-4.73; p = 0.17). CONCLUSIONS: In this first study of survival after transfusion in France, there was no significant effect for age of blood or donor sex. Contrary to previously reported data, female RBCs appear to be safe for male recipients.