Acute respiratory distress syndrome in patients with hematological malignancies: a one-year retrospective nationwide cohort study.

BACKGROUND: Acute respiratory distress syndrome (ARDS) occurring in patients with hematological malignancies (HM) is a life-threatening condition with specific features. Mortality rate remains high but improvement has been described over the past several years. We aimed to describe characteristics and outcomes of ARDS in HM patients admitted in French ICUs (Intensive Care Units) during a one year-period. Data for this nationwide cohort study were collected from the French national hospital database (Programme de Médicalisation des Systèmes d'Information (PMSI)). All patients (18 years or older) admitted to French ICUs in 2017 and with a diagnosis of ARDS were included. Three groups were compared according to the presence of an HM, a solid cancer or no cancer. The primary endpoint was 90-day mortality. Secondary endpoints were the description of ICU management, etiologies of ARDS and mortality risk factors. RESULTS: A total of 12 846 patients with ARDS were included. Among them, 990 had HM and 2744 had a solid cancer. The main malignancies were non-Hodgkin lymphoma (NHL) (28.5%), acute myeloid leukemia (AML) (20.4%) and multiple myeloma (19.7%). Day-90 mortality in patients with HM was higher than in patients with no cancer (64.4% vs. 46.6% p = 0.01) but was not different from that of patients with solid cancer (64.4% vs. 61.4%,p = 0.09). Intubation rate was lower in patients with HM in comparison with both groups (87.7% vs. 90.4% p = 0.02 for patients with solid cancer and 87.7% vs. 91.3%; p < 0.01 with no cancer). Independent predictors of mortality for patients with HM were a diagnosis of lymphoma or acute leukemia, age, a high modified SAPS II score, a renal replacement therapy, invasive fungal infection, and a septic shock. Bacterial pneumonia, extrapulmonary infections and non-invasive ventilation were protective. CONCLUSION: Mortality remains high in patients with HM admitted in ICU with ARDS in comparison with patients without cancer. Mortality predictors for this population were a diagnosis of lymphoma or acute leukemia, age, a high modified SAPS II score, a renal replacement therapy, invasive fungal infection and a septic shock.

Association between hospital procedure volume, socioeconomic status, comorbidities, and adverse events related to surgical abortion: A nationwide population-based cohort study.

BACKGROUND: Limited evidence exists on the influence of hospital procedure volume, socioeconomic status, and comorbidities on surgical abortion outcomes. OBJECTIVE: Our study aimed to assess the association between hospital procedure volume, individual and neighborhood deprivation, comorbidities, and abortion-related adverse events. STUDY DESIGN: A nationwide population-based cohort study of all women hospitalized for surgical abortion was conducted from January 1, 2018, to December 31, 2019 in France. Annual hospital procedure volume was categorized into four levels based on spline function visualization: very low (<80), low ([80-300[), high ([300-650[), and very high-volume (≥650) centers. The primary outcome was the occurrence of at least one surgical-related adverse event, including hemorrhage, retained products of conception, genital tract and pelvic infection, transfusion, fistulas and neighboring lesions, local hematoma, failure of abortion, admission to an intensive care unit or death. These events were monitored during the index stay and during a subsequent hospitalization up to 90 days. The secondary outcome encompassed general adverse events not directly linked to surgery. RESULTS: Of the 112,842 hospital stays, 4,951 (4.39%) had surgical-related adverse events and 256 (0.23%) had general adverse events. The multivariate analysis showed a volume-outcome relationship, with lower rates of surgical-related adverse events in very high-volume (2.25%, aOR=0.34, 95%CI [0.29-0.39], p<0.001), high-volume (4.24%, aOR=0.61, 95%CI [0.55-0.69], p<0.001), and low-volume (4.69%, aOR=0.81, 95%CI [0.75-0.88], p<0.001) when compared to very low-volume centers (6.65%). Individual socioeconomic status (aOR=1.69, 95%CI [1.47-1.94], p<0.001), neighborhood deprivation (aOR=1.31, 95% CI [1.22-1.39], p<0.001), and comorbidities (aOR=1.79, 95%CI [1.35-2.38], p<0.001) were associated with surgical-related adverse events. Conversely, the multivariate analysis of general adverse events did not reveal any volume-outcome relationship. CONCLUSION: The presence of a volume-outcome relationship underscores the need for enhanced safety standards in low-volume centers to ensure equity in women's safety during surgical abortions. However, our findings also highlight the complexity of this safety concern which involves multiple other factors including socioeconomic status and comorbidities that policymakers must consider.

The impact of hospital saturation on non-COVID-19 hospital mortality during the pandemic in France: a national population-based cohort study.

BACKGROUND: A previous study reported significant excess mortality among non-COVID-19 patients due to disrupted surgical care caused by resource prioritization for COVID-19 cases in France. The primary objective was to investigate if a similar impact occurred for medical conditions and determine the effect of hospital saturation on non-COVID-19 hospital mortality during the first year of the pandemic in France. METHODS: We conducted a nationwide population-based cohort study including all adult patients hospitalized for non-COVID-19 acute medical conditions in France between March 1, 2020 and 31 May, 2020 (1st wave) and September 1, 2020 and December 31, 2020 (2nd wave). Hospital saturation was categorized into four levels based on weekly bed occupancy for COVID-19: no saturation (< 5%), low saturation (> 5% and ≤ 15%), moderate saturation (> 15% and ≤ 30%), and high saturation (> 30%). Multivariate generalized linear model analyzed the association between hospital saturation and mortality with adjustment for age, sex, COVID-19 wave, Charlson Comorbidity Index, case-mix, source of hospital admission, ICU admission, category of hospital and region of residence. RESULTS: A total of 2,264,871 adult patients were hospitalized for acute medical conditions. In the multivariate analysis, the hospital mortality was significantly higher in low saturated hospitals (adjusted Odds Ratio/aOR = 1.05, 95% CI [1.34-1.07], P < .001), moderate saturated hospitals (aOR = 1.12, 95% CI [1.09-1.14], P < .001), and highly saturated hospitals (aOR = 1.25, 95% CI [1.21-1.30], P < .001) compared to non-saturated hospitals. The proportion of deaths outside ICU was higher in highly saturated hospitals (87%) compared to non-, low- or moderate saturated hospitals (81-84%). The negative impact of hospital saturation on mortality was more pronounced in patients older than 65 years, those with fewer comorbidities (Charlson 1-2 and 3 vs. 0), patients with cancer, nervous and mental diseases, those admitted from home or through the emergency room (compared to transfers from other hospital wards), and those not admitted to the intensive care unit. CONCLUSIONS: Our study reveals a noteworthy "dose-effect" relationship: as hospital saturation intensifies, the non-COVID-19 hospital mortality risk also increases. These results raise concerns regarding hospitals' resilience and patient safety, underscoring the importance of identifying targeted strategies to enhance resilience for the future, particularly for high-risk patients.

High-resolution ultrasound of the paratenon of the Achilles calcaneal tendon: anatomical study and description of the paratendinous injection technique.

PURPOSE: The aim of this study is to determine if ultrasound (US) allows a precise assessment of the paratenon (PT) of the Achilles calcaneal tendon (AT), and to anatomically describe the US-guided paratendinous injection technique. METHODS: This study was initially conducted on eight cadaveric specimens using high-resolution ultrasound (HRUS) to examine the PT appearance, thickness, and its relationships with the AT, plantaris tendon (PLT), Kager's fat pad (KFP), sural nerve (SN), and fascia cruris (FC). US-guided paratendinous injection of China ink was performed in all specimens, followed by anatomical dissection to assess injectate distribution. Then, HRUS study of the PT was carried out bilaterally in twenty asymptomatic volunteers (40 legs). Two musculoskeletal radiologists recorded all data in consensus except PT thickness in volunteers which was recorded independently in order to calculate intra and inter-observer reliability. RESULTS: The PT was consistently identified with HRUS along its entire course in both cadaveric specimens (8/8) and volunteers (40/40). The mean PT thickness was 0.54 mm in cadavers and 0.39 mm in vivo, without any correlation with the AT thickness. Intra- and inter observer reliability were respectively excellent and good for PT thickness. All eight (100%) ex vivo China ink injections were accurate, demonstrating a circumferential distribution of the injectate between the PT and the AT, associated with an anterior spread to the KFP. CONCLUSION: HRUS allows visualization of the PT along its entire length, and assessment of its relationships to adjacent structures. US-guided paratendinous injections can accurately and safely deliver injectates in the paratendinous sheath.

Association of Standardized Parenteral Nutrition with Early Neonatal Growth of Moderately Preterm Infants: A Population-Based Cohort Study.

In preterm infants, early nutrient intake during the first week of life often depends on parenteral nutrition. This study aimed to evaluate the influence of standardized parenteral nutrition using three-in-one double-chamber solutions (3-in-1 STD-PN) on early neonatal growth in a cohort of moderately preterm (MP) infants. This population-based, observational cohort study included preterm infants admitted to neonatal centers in the southeast regional perinatal network in France. During the study period, 315 MP infants with gestational ages between 320/7 and 346/7 weeks who required parenteral nutrition from birth until day-of-life 3 (DoL3) were included; 178 received 3-in-1 STD-PN solution (56.5%). Multivariate regression was used to assess the factors associated with the relative body-weight difference between days 1 and 7 (RBWD DoL1-7). Infants receiving 3-in-1 STD-PN lost 36% less body weight during the first week of life, with median RBWD DoL1-7 of -2.5% vs. -3.9% in infants receiving other PN solutions (p < 0.05). They also received higher parenteral energy and protein intakes during the overall first week, with 85% (p < 0.0001) and 27% (p < 0.0001) more energy and protein on DoL 3. After adjusting for confounding factors, RBWD DoL1-7 was significantly lower in the 3-in-1 STD-NP group than in their counterparts, with beta (standard deviation) = 2.08 (0.91), p = 0.02. The use of 3-in-1 STD-PN provided better energy and protein intake and limited early weight loss in MP infants.

Reduced mortality associated to cementless total hip arthroplasty in femoral neck fracture.

Mortality related to femoral neck fractures remains a challenging health issue, with a high mortality rate at 1 year of follow-up. Three modifiable factors appear to be under control of the surgeon: the choice of the implant, the use of cement and the timing before surgery. The aim of this research project was to study the impact on mortality each of these risk factors play during the management of femoral neck fractures. A large retrospective epidemiological study was performed using a national database of the public healthcare system. The inclusion criteria were patients who underwent joint replacement surgery after femoral neck fracture during the years 2015 to 2017. All data points were available for at least 2 years after the fracture. The primary outcome was mortality within 2 years following the surgery. We evaluated the association between mortality and the type of the implant hemiarthroplasty (HA) versus total hip arthroplasty (THA), cemented versus non cemented femoral stem as well as the timing from fracture to surgical procedure. A multivariate analysis was performed including age, gender, comorbidities/autonomy scores, social category, and obesity. We identified 96,184 patients who matched the inclusion criteria between 2015 and 2017. 64,106 (66%) patients underwent HA and 32,078 (33.4%) underwent THA. After multivariate analysis including age and comorbidities, patients who underwent surgery after 72 h intra-hospital had a higher risk of mortality: Hazard Ratio (HR) = 1.119 (1.056-1.185) p = 0.0001 compared to the group who underwent surgery within 24 h. THA was found to be a protective factor HR = 0.762 (0.731-0.795) p < 0.0001. The use of cement was correlated with higher mortality rate: HR = 1.107 (1.067-1.149) p < 0.0001. Three key points are highlighted by our study in the reduction of mortality related to femoral neck fracture: the use of hemiarthroplasty a surgery performed after 48 h and the use of cement for femoral stem fixation adversely affect mortality risk.

COVID-19 among undocumented migrants admitted to French intensive care units during the 2020-2021 period: a retrospective nationwide study.

BACKGROUND: Before the Coronavirus Disease 2019 (COVID-19) pandemic in France, undocumented migrants had a higher risk than general population for being admitted to the intensive care unit (ICU) because of acute respiratory failure or severe infection. Specific data concerning the impact of COVID-19 on undocumented migrants in France are lacking. We aimed to analyze the mortality and respiratory severity of COVID-19 in this specific population. We retrospectively included all undocumented adult migrants admitted in French ICUs from March 2020 through April 2021 using the French nationwide hospital information system (Programme de Médicalisation des Systèmes d'Information). We focused on admissions related to COVID-19. Undocumented migrants were compared to the general population, first in crude analysis, then after matching on age, severity and main comorbidities. The primary outcome was the ICU mortality from COVID-19. Secondary objectives were the incidence of acute respiratory distress syndrome (ARDS), the need for mechanical ventilation (MV), the duration of MV, ICU and hospital stay. RESULTS: During the study period, the rate of ICU admission among patients hospitalized for COVID-19 was higher for undocumented migrants than for general population (463/1627 (28.5%) vs. 81 813/344 001 (23.8%); p < 0.001). Although ICU mortality was comparable after matching (14.3% for general population vs. 13.3% for undocumented migrants; p = 0.50), the incidence of ARDS was higher among undocumented migrants (odds ratio, confidence interval (OR (CI)) 1.25 (1.06-1.48); p = 0.01). Undocumented migrants needed more frequently invasive MV (OR (CI) 1.2 (1.01-1.42); p = 0.04 than general population. There were no differences between groups concerning duration of MV, ICU and hospital length of stay. CONCLUSION: During the first waves of COVID-19 in France, undocumented migrants had a mortality similar to the general population but a higher risk for ICU admission and for developing an ARDS. These results highlight the need for reinforcing prevention and improving primary healthcare access for people in irregular situation.

Effects of ambient air pollutants on ARDS incidence and outcome: a narrative review.

BACKGROUND: Exposure to air pollutants promotes inflammation, cancer, and mortality in chronic diseases. Acute respiratory distress syndrome (ARDS) is a common condition among intensive care unit patients and is associated with a high mortality rate. ARDS is characterized by significant lung inflammation, which can be replicated in animal models by acute exposure to high doses of various air pollutants. Recently, several clinical studies have been conducted in different countries to investigate the role of chronic or acute air pollutant exposure in enhancing both ARDS incidence and severity. RESULTS: Chronic exposure studies have mainly been conducted in the US and France. The results of these studies suggest that some air pollutants, notably ozone, nitrogen dioxide, and particulate matter, increase susceptibility to ARDS and associated mortality. Furthermore, their impact may differ according to the cause of ARDS. A cohort study conducted in an urbanized zone in China showed that exposure to very high levels of air pollutants in the few days preceding intensive care unit admission was associated with an increased incidence of ARDS. The effects of acute exposure are more debatable regarding ARDS incidence and severity. CONCLUSION: There is a likely relationship between air pollutant exposure and ARDS incidence and severity. However, further studies are required to determine which pollutants are the most involved and which patients are the most affected. Due to the prevalence of ARDS, air pollutant exposure may have a significant impact and could be a key public health issue.

Peripheral location of lung cancer is associated with higher local disease recurrence.

OBJECTIVES: Our goal was to evaluate the association between the distance of the tumour to the visceral pleura and the rate of local recurrence in patients surgically treated for stage pI lung cancer. METHODS: We conducted a single-centre retrospective review of 578 consecutive patients with clinical stage IA lung cancer who underwent a lobectomy or segmentectomy from January 2010 to December 2019. We excluded 107 patients with positive margins, previous lung cancer, neoadjuvant treatment and pathological stage II or higher status or for whom preoperative computed tomography (CT) scans were not available at the time of the study. The distance between the tumour and the closest visceral pleura area (fissure/mediastinum/lateral) was assessed by 2 independent investigators who used preoperative CT scans and multiplanar 3-dimensional reconstructions. An area under the receiver operating characteristic curve analysis was performed to determine the best threshold for the tumour/pleura distance. Then multivariable survival analyses were used to assess the relationship between local recurrence and this threshold in relation to other variables. RESULTS: Local recurrence occurred in 27/471 patients (5.8%). A cut-off value of 5 mm between the tumour and the pleura was determined statistically. In the multivariable analysis, the local recurrence rate was significantly higher in patients with a tumour-to-pleura distance ≤5 mm compared to patients with a tumour-to-pleura distance >5 mm (8.5% vs 2.7%, hazard ratio 3.36, 95% confidence interval: 1.31-8.59, P = 0.012). Subgroup analyses of patients with pIA and tumour size ≤2 cm identified local recurrences in 4/78 patients treated with segmentectomy (5.1%), with a significantly higher occurrence with tumour-to-pleura distances ≤5 mm (11.4% vs 0%, P = 0.037), and in 16/292 patients treated with lobectomy (5.5%) without significant higher occurrence in tumour-to-pleura distances of ≤5 mm (7.7% vs 3.4%, P = 0.13). CONCLUSIONS: The peripheral location of a lung tumour is associated with a higher rate of local recurrence and should be taken into account during preoperative planning when considering segmental versus lobar resection.

Association of severe mental illness and septic shock case fatality rate in patients admitted to the intensive care unit: A national population-based cohort study.

BACKGROUND: Patients with severe mental illness (SMI) (i.e., schizophrenia, bipolar disorder, or major depressive disorder) have been reported to have excess mortality rates from infection compared to patients without SMI, but whether SMI is associated with higher or lower case fatality rates (CFRs) among infected patients remains unclear. The primary objective was to compare the 90-day CFR in septic shock patients with and without SMI admitted to the intensive care unit (ICU), after adjusting for social disadvantage and physical health comorbidity. METHODS AND FINDINGS: We conducted a nationwide, population-based cohort study of all adult patients with septic shock admitted to the ICU in France between January 1, 2014, and December 31, 2018, using the French national hospital database. We matched (within hospitals) in a ratio of 1:up to 4 patients with and without SMI (matched-controls) for age (5 years range), sex, degree of social deprivation, and year of hospitalization. Cox regression models were conducted with adjustment for smoking, alcohol and other substance addiction, overweight or obesity, Charlson comorbidity index, presence of trauma, surgical intervention, Simplified Acute Physiology Score II score, organ failures, source of hospital admission (home, transfer from other hospital ward), and the length of time between hospital admission and ICU admission. The primary outcome was 90-day CFR. Secondary outcomes were 30- and 365-day CFRs, and clinical profiles of patients. A total of 187,587 adult patients with septic shock admitted to the ICU were identified, including 3,812 with schizophrenia, 2,258 with bipolar disorder, and 5,246 with major depressive disorder. Compared to matched controls, the 90-day CFR was significantly lower in patients with schizophrenia (1,052/3,269 = 32.2% versus 5,000/10,894 = 45.5%; adjusted hazard ratio (aHR) = 0.70, 95% confidence interval (CI) 0.65,0.75, p < 0.001), bipolar disorder (632/1,923 = 32.9% versus 2,854/6,303 = 45.3%; aHR = 0.70, 95% CI = 0.63,0.76, p < 0.001), and major depressive disorder (1,834/4,432 = 41.4% versus 6,798/14,452 = 47.1%; aHR = 0.85, 95% CI = 0.81,0.90, p < 0.001). Study limitations include inability to capture deaths occurring outside hospital, lack of data on processes of care, and problems associated with missing data and miscoding in medico-administrative databases. CONCLUSIONS: Our findings suggest that, after adjusting for social disadvantage and physical health comorbidity, there are improved septic shock outcome in patients with SMI compared to patients without. This finding may be the result of different immunological profiles and exposures to psychotropic medications, which should be further explored.

Total hip arthroplasty reduces the risk of dislocation after femoral neck fracture.

INTRODUCTION: Femoral neck fracture in the elderly patient can either be managed using hemi-arthroplasty (HA) or total hip arthroplasty (THA). The aim of this study was to explore the rate of three selected complications in each procedure: is the dislocation rate higher with HA compared to THA? Is the blood transfusion rate higher with THA compared to HA? Do the patients who underwent THA require more ICU transfer than the patients who underwent HA? Is the ICU transfer correlated to the use of cement for stem fixation? METHOD: Based on a national health-care database, a comparative and retrospective study was conducted. 96,184 patients were included after having a surgery for femoral neck fracture between 2014 and 2017. The mean follow up was 3.5 years (Min. 2 years-Max. 5 years). The population was divided into two groups: hemiarthroplasty (HA) and total hip arthroplasty (THA). The primary outcome was the dislocation rate and the secondary outcomes were the blood transfusion rate and the need for ICU after surgery. RESULTS: At two years of follow up in the Hemiarthroplasty group, 3647 patients had a dislocation episode over 64,106 patients: 5.69%. In the Total Hip Arthroplasty group: 1904 patients had a dislocation episode over 32,078 patients: 5.94% (p=0.26711). The percentage of deceased patient without dislocation was 17.76% in the HA group and 11.56% in the THA group (p<0.001). The univariate hazard ratio for dislocation was higher in the THA group: HR 1.063 IC 95% (0.993-1.138) p=0.077. The multivariate analysis calculating competitive risk with death and dislocation found THA to be a protective factor of dislocation HR 0.926 IC 95% (0.866-0.991) p=0.0266. The rate of blood transfusion was 5.59% in the THA group and 7.03% in the HA group (p<0.001), The multivariate analysis found HR=1.062 IC 95% (0.99-1.139) p=0.0955. The need for ICU transfer after the surgery was 7.04% in the HA group and 8.08% in the THA group (p<0.001). The multivariate analysis found HR 0.995 IC 95% (0.921-1.076) p=0.9094. Finally, only cement was found as an independent risk factor of ICU transfer after surgery: HR 1.254 IC 95% (1.164-1.35) p<0.0001. CONCLUSION: THA for femoral neck fracture allows to reduce the risk of dislocation compared to hemiarthroplasty. The multivariate analysis failed to prove the superiority of one procedure over the other regarding blood transfusion risk and the need for ICU transfer. The use of cemented stem appears to be a risk factor of ICU transfer after hip arthroplasty. LEVEL OF EVIDENCE: III, Retrospective comparative study.

Symptom Screening in Pediatrics Tool in children and adolescents with high-risk malignancies: a pilot study.

OBJECTIVE: Childhood and adolescent cancer can result in high burden of distressing symptoms, particularly in high-risk malignancies. The Symptom Screening in Pediatrics Tool (SSPedi) is a reliable and valid approach to measure bothersome symptoms in paediatric patients receiving cancer treatments. Objective was to describe the feasibility of using SSPedi administration among paediatric patients with high-risk malignancies. METHODS: We conducted a single-centre, cross-sectional study of patients aged 8-18 years with high-risk malignancies in a French paediatric oncology unit. Patients self-reported the degree of bothersome symptoms using SSPedi and difficulty with SSPedi completion. The total SSPedi Score ranging from 0 to 60 (where 60 is worst) and most common moderately bothersome symptoms (scored ≥2 on 0-4 Likert Scale) were described. Feasibility was defined as more than 75% of patients agreeing to participate and more than 90% completion of SSPedi questionnaire. RESULTS: Out of 16 patients approached, 1 declined participation. Median age was 13 years (IQR 8-19). All were able to self-report SSPedi without difficulty. Patients experienced a median number of 6 (range 0-15) bothersome symptoms (score >0). The mean total SSPedi Score was 12 (SD=9.4). Most common moderately bothersome symptoms were pain (8/15), changes in hunger (8/15) and feeling tired (7/15). CONCLUSION: Patient-reported symptom assessment among children and adolescents with high-risk malignancies is feasible using SSPedi. These patients experience a high burden of bothersome symptoms.

Mortality among inpatients with bipolar disorders and COVID-19: a propensity score matching analysis in a national French cohort study.

BACKGROUND: It remains unknown whether coronavirus disease 2019 (COVID-19) patients with bipolar disorders (BDs) are at an increased risk of mortality. We aimed to establish whether health outcomes and care differed between patients infected with COVID-19 with BD and patients without a diagnosis of severe mental illness. METHODS: We conducted a population-based cohort study of all patients with identified COVID-19 and respiratory symptoms who were hospitalized in France between February and June 2020. The outcomes were in-hospital mortality and intensive care unit (ICU) admission. We used propensity score matching to control for confounding factors. RESULTS: In total, 50 407 patients were included, of whom 480 were patients with BD. Patients with BD were 2 years older, more frequently women and had more comorbidities than controls without a diagnosis of severe mental illness. Patients with BD had an increased in-hospital mortality rate (26.6% v. 21.9%; p = 0.034) and similar ICU admission rate (27.9% v. 28.4%, p = 0.799), as confirmed by propensity analysis [odds ratio, 95% confidence interval (OR, 95% CI) for mortality: 1.30 (1.16-1.45), p < 0.0001]. Significant interactions between BD and age and between BD and social deprivation were found, highlighting that the most important inequalities in mortality were observed in the youngest [OR, 95% CI 2.28 (1.18-4.41), p = 0.0015] and most deprived patients with BD [OR, 95% CI 1.60 (1.33-1.92), p < 0.001]. CONCLUSIONS: COVID-19 patients with BD were at an increased risk of mortality, which was exacerbated in the youngest and most deprived patients with BD. Patients with BD should thus be targeted as a high-risk population for severe forms of COVID-19, requiring enhanced preventive and disease management strategies.

Machine-learning prediction for hospital length of stay using a French medico-administrative database.

INTRODUCTION: Prolonged Hospital Length of Stay (PLOS) is an indicator of deteriorated efficiency in Quality of Care. One goal of public health management is to reduce PLOS by identifying its most relevant predictors. The objective of this study is to explore Machine Learning (ML) models that best predict PLOS. METHODS: Our dataset was collected from the French Medico-Administrative database (PMSI) as a retrospective cohort study of all discharges in the year 2015 from a large university hospital in France (APHM). The study outcomes were LOS transformed into a binary variable (long vs. short LOS) according to the 90th percentile (14 days). Logistic regression (LR), classification and regression trees (CART), random forest (RF), gradient boosting (GB) and neural networks (NN) were applied to the collected data. The predictive performance of the models was evaluated using the area under the ROC curve (AUC). RESULTS: Our analysis included 73,182 hospitalizations, of which 7,341 (10.0%) led to PLOS. The GB classifier was the most performant model with the highest AUC (0.810), superior to all the other models (all p-values <0.0001). The performance of the RF, GB and NN models (AUC ranged from 0.808 to 0.810) was superior to that of the LR model (AUC = 0.795); all p-values <0.0001. In contrast, LR was superior to CART (AUC = 0.786), p < 0.0001. The variable most predictive of the PLOS was the destination of the patient after hospitalization to other institutions. The typical clinical profile of these patients (17.5% of the sample) was the elderly patient, admitted in emergency, for a trauma, a neurological or a cardiovascular pathology, more often institutionalized, with more comorbidities notably mental health problems, dementia and hemiplegia. DISCUSSION: The integration of ML, particularly the GB algorithm, may be useful for health-care professionals and bed managers to better identify patients at risk of PLOS. These findings underscore the need to strengthen hospitals through targeted allocation to meet the needs of an aging population.

Vertebral trabecular bone texture analysis in opportunistic MRI and CT scan can distinguish patients with and without osteoporotic vertebral fracture: A preliminary study.

PURPOSE: To investigate the potential of texture parameters from opportunistic MRI and CT for the detection of patients with vertebral fragility fracture, to design a decision tree and to compute a Random Forest analysis for the prediction of fracture risk. METHODS: One hundred and eighty vertebrae of sixty patients with at least one (30) or without (30) a fragility fracture were retrospectively assessed. Patients had a DXA, an MRI and a CT scan from the three first lumbar vertebrae. Vertebrae texture analysis was performed in routine abdominal or lumbar CT and lumbar MRI using 1st and 2nd order texture parameters. Hounsfield Unit Bone density (HU BD) was also measured on CT-scan images. RESULTS: Twelve texture parameters, Z-score and HU BD were significantly different between the two groups whereas T score and BMD were not. The inter observer reproducibility was good to excellent. Decision tree showed that age and HU BD were the most relevant factors to predict the fracture risk with a 93 % sensitivity and 56 % specificity. AUC was 0.91 in MRI and 0.92 in CT-scan using the Random Forest analysis. The corresponding sensitivity and specificity were 72 % and 93 % in MRI and 83 and 89 % in CT. CONCLUSIONS: This study is the first to compare texture indices computed from opportunistic CT and MR images. Age and HU-BD together with selected texture parameters could be used to assess risk fracture. Machine learning algorithm can detect fracture risk in opportunistic CT and MR imaging and might be of high interest for the diagnosis of osteoporosis.

Eosinopenia as Predictor of Poor Outcome in Hospitalized COVID-19 Adult Patients from Waves 1 and 2 of 2020 Pandemic.

During SARS-CoV-2 infection, eosinopenia may reflect a hyperactive immune response. In this study of hospitalized COVID-19 patients, we aimed to better understand the prognostic value of severe eosinopenia (absolute eosinophil count = 0 G/L) and decipher its underlying mechanisms. We retrospectively analyzed the records of COVID-19 patients hospitalized from March to June 2020 in three university hospitals in Marseille, France. We assessed the association between severe eosinopenia and a composite poor outcome in these patients, including the need for oxygen supplementation at >6 L/min, ICU admission, and in-hospital death. Among the 551 COVID-19 patients included in this study, severe eosinopenia was found in 228 (51%) of them on admission to hospital and was associated with a composite poor outcome using multivariate analysis (OR = 2.58; CI95 [1.77−3.75]; p < 0.0001). We found a significant association between the presence of severe eosinopenia on admission and the elevation in C-reactive protein, ferritin, IP-10, and suPAR. The histological findings in a series of 37 autopsies from patients who died from severe COVID-19 and presented with severe eosinopenia showed no pulmonary eosinophil trapping. Severe eosinopenia can be a reliable biomarker associated with a composite poor outcome in hospitalized COVID-19 adult patients. It may reflect the magnitude of immune hyperactivation during severe-to-critical COVID-19.

Texture Parameters Measured by UHF-MRI and CT Scan Provide Information on Bone Quality in Addition to BMD: A Biomechanical Ex Vivo Study.

The current definition of osteoporosis includes alteration of bone quality. The assessment of bone quality is improved by the development of new texture analysis softwares. Our objectives were to assess if proximal femoral trabecular bone texture measured in Ultra high field (UHF) 7 Tesla MRI and CT scan were related to biomechanical parameters, and if the combination of texture parameters and areal bone mineral density (aBMD) measured by dual-energy X-ray absorptiometry provided a better prediction of femoral failure than aBMD alone. The aBMD of 16 proximal femur ends from eight cadavers were investigated. Nineteen textural parameters were computed in three regions or volumes of interest for each specimen on UHF MRI and CT scan. Then, the corresponding failure load and failure stress were calculated thanks to mechanical compression test. aBMD was not correlated to failure load (R2 = 0.206) and stress (R2 = 0.153). The failure load was significantly correlated with ten parameters in the greater trochanter using UHF MRI, and with one parameter in the neck and the greater trochanter using CT scan. Eight parameters in the greater trochanter using UHF MRI combined with aBMD improved the failure load prediction, and seven parameters improved the failure stress prediction. Our results suggest that textural parameters provide additional information on the fracture risk of the proximal femur when aBMD is not contributive.

Impact of the COVID-19 pandemic on non-COVID-19 hospital mortality in patients with schizophrenia: a nationwide population-based cohort study.

It remains unknown to what degree resource prioritization toward SARS-CoV-2 (2019-nCoV) coronavirus (COVID-19) cases had disrupted usual acute care for non-COVID-19 patients, especially in the most vulnerable populations such as patients with schizophrenia. The objective was to establish whether the impact of the COVID-19 pandemic on non-COVID-19 hospital mortality and access to hospital care differed between patients with schizophrenia versus without severe mental disorder. We conducted a nationwide population-based cohort study of all non-COVID-19 acute hospitalizations in the pre-COVID-19 (March 1, 2019 through December 31, 2019) and COVID-19 (March 1, 2020 through December 31, 2020) periods in France. We divided the population into patients with schizophrenia and age/sex-matched patients without severe mental disorder (1:10). Using a difference-in-differences approach, we performed multivariate patient-level logistic regression models (adjusted odds ratio, aOR) with adjustment for complementary health insurance, smoking, alcohol and substance addiction, Charlson comorbidity score, origin of the patient, category of care, intensive care unit (ICU) care, major diagnosis groups and hospital characteristics. A total of 198,186 patients with schizophrenia were matched with 1,981,860 controls. The 90-day hospital mortality in patients with schizophrenia increased significantly more versus controls (aOR = 1.18; p < 0.001). This increased mortality was found for poisoning and injury (aOR = 1.26; p = 0.033), respiratory diseases (aOR = 1.19; p = 0.008) and for both surgery (aOR = 1.26; p = 0.008) and medical care settings (aOR = 1.16; p = 0.001). Significant changes in the case mix were noted with reduced admission in the ICU and for several somatic diseases including cancer, circulatory and digestive diseases and stroke for patients with schizophrenia compared to controls. These results suggest a greater deterioration in access to, effectiveness and safety of non-COVID-19 acute care in patients with schizophrenia compared to patients without severe mental disorders. These findings question hospitals' resilience pertaining to patient safety and underline the importance of developing specific strategies for vulnerable patients in anticipation of future public health emergencies.