What is the rate of definitive stoma after subtotal colectomy for inflammatory bowel disease? A nationwide study of 1860 patients.

AIM: Some patients with inflammatory bowel disease (IBD) require subtotal colectomy (STC) with ileostomy. The recent literature reports a significant number of patients who do not undergo subsequent surgery and are resigned to living with a definitive stoma. The aim of this work was to analyse the rate of definitive stoma and the cumulative incidence of secondary reconstructive surgery after STC for IBD in a large national cohort study. METHOD: A national retrospective study (2013-2021) was conducted on prospectively collected data from the French Medical Information System Database (PMSI). All patients undergoing STC in France were included. The association between definitive stoma and potential risk factors was studied using univariate and multivariate analyses. RESULTS: A total of 1860 patients were included (age 45 ± 9 years; median follow-up 30 months). Of these, 77% (n = 1442) presented with ulcerative colitis. Mortality and morbidity at 90 days after STC were 5% (n = 100) and 47% (n = 868), respectively. Reconstructive surgery was identified in 1255 patients (67%) at a mean interval of 7 months from STC. Seveny-four per cent (n = 932) underwent a completion proctectomy with ileal pouch anal anastomosis and 26% (n = 323) an ileorectal anastomosis. Six hundred and five (33%) patients with a definitive stoma had an abdominoperineal resection (n = 114; 19%) or did not have any further surgical procedure (n = 491; 81%). Independent risk factors for definitive stoma identified in multivariate analysis were older age, Crohn's disease, colorectal neoplasia, postoperative complication after STC, laparotomy and a low-volume hospital. CONCLUSION: We found that 33% of patients undergoing STC with ileostomy for IBD had definitive stoma. Modifiable risk factors for definitive stoma were laparotomy and a low-volume hospital.

Effect of bariatric surgery on cancer risk: results from an emulated target trial using population-based data.

BACKGROUND: The impact of weight loss induced by bariatric surgery on cancer occurrence is controversial. To study the causal effect of bariatric surgery on cancer risk from an observational database, a target-trial emulation technique was used to mimic an RCT. METHODS: Data on patients admitted between 2010 and 2019 with a diagnosis of obesity were extracted from a national hospital discharge database. Criteria for inclusion included eligibility criteria for bariatric surgery and the absence of cancer in the 2 years following inclusion. The intervention arms were bariatric surgery versus no surgery. Outcomes were the occurrence of any cancer and obesity-related cancer; cancers not related to obesity were used as negative controls. RESULTS: A total of 1 140 347 patients eligible for bariatric surgery were included in the study. Some 288 604 patients (25.3 per cent) underwent bariatric surgery. A total of 48 411 cancers were identified, including 4483 in surgical patients and 43 928 among patients who did not receive bariatric surgery. Bariatric surgery was associated with a decrease in the risk of obesity-related cancer (hazard ratio (HR) 0.89, 95 per cent c.i. 0.83 to 0.95), whereas no significant effect of surgery was identified with regard to cancers not related to obesity (HR 0.96, 0.91 to 1.01). CONCLUSION: When emulating a target trial from observational data, a reduction of 11 per cent in obesity-related cancer was found after bariatric surgery.

Risk Stratification in COVID-19 Pneumonia - Determining the Role of Lung Ultrasound.

LUS patterns of COVID-19 pneumonia have been described and shown to be characteristic. The aim of the study was to predict the prognosis of patients with COVID-19 pneumonia, using a score based on LUS findings. MATERIALS AND METHODS: An observational, retrospective study was conducted on patients admitted to Niguarda hospital with a diagnosis of COVID-19 pneumonia during the period of a month, from March 2nd to April 3rd 2020. Demographics, clinical, laboratory, and radiological findings were collected. LUS was performed in all patients. The chest was divided into 12 areas. The LUS report was drafted using a score from 0 to 3 with 0 corresponding to A pattern, 1 corresponding to well separated vertical artifacts (B lines), 2 corresponding to white lung and small consolidations, 3 corresponding to wide consolidations. The total score results from the sum of the scores for each area. The primary outcome was endotracheal intubation, no active further management, or death. The secondary outcome was discharge from the emergency room (ER). RESULTS: 255 patients were enrolled. 93.7 % had a positive LUS. ETI was performed in 43 patients, and 24 received a DNI order. The general mortality rate was 15.7 %. Male sex (OR 3.04, p = 0.014), cardiovascular disease and hypertension (OR 2.75, p = 0.006), P/F (OR 0.99, p < 0.001) and an LUS score > 20 (OR 2.52, p = 0.046) were independent risk factors associated with the primary outcome. Receiver operating characteristic (ROC) curve analysis for an LUS score > 20 was performed with an AUC of 0.837. Independent risk factors associated with the secondary outcome were age (OR 0.96, p = 0.073), BMI (OR 0.87, p = 0,13), P/F (OR 1.03, p < 0.001), and LUS score < 10 (OR 20.9, p = 0.006). ROC curve analysis was performed using an LUS score < 10 with an AUC 0.967. CONCLUSION: The extent of lung abnormalities evaluated by LUS score is a predictor of a worse outcome, ETI, or death. Moreover, the LUS score could be an additional tool for the safe discharge of patient from the ER.

Impact of Oral Immunonutrition on Postoperative Morbidity in Digestive Oncologic Surgery: A Nation-wide Cohort Study.

OBJECTIVE: The objective of the present study was to assess the effect of preoperative immunonutrition on a nationwide scale. BACKGROUND: According to international guidelines, immunonutrition should be prescribed before major oncologic digestive surgery to decrease postoperative morbidity. Nevertheless, this practice remains controversial. METHODS: We used a prospective national health database named "Echantillon généraliste des Bénéficiaires." Patients were selected with ICD10 codes of cancer and digestive surgery procedures from 2012 to 2016. Two groups were identified: with reimbursement of immunonutrition 45 days before surgery (IN-group) or not (no-IN-group). Primary outcome was 90-day severe morbidity. Secondary outcomes were postoperative length of stay (LOS) and overall survival. Logistic regression and survival analysis adjusted with IPW method were performed. RESULTS: One thousand seven hundred seventy-one patients were included. The proportion of different cancers was as follows: 72% patients were included in the colorectal group, 14% in the hepato-pancreato-biliary group, and 12% in the upper gastrointestinal group. Patients from the IN-group (n = 606, 34%) were younger (67.1 ±â€Š11.8 vs 69.2 ±â€Š12.2 years, P < 0.001), with increased use of other oral nutritional supplements (49.5% vs 31.8%, P < 0.001) and had more digestive anastomoses (89.4% vs 83.0%, P < 0.001). There was no significant difference between the 2 groups for 90-day severe morbidity [odds ratio (OR): 0.91, 95% confidence interval (95% CI): 0.73-1.14] or in survival (hazard ratio: 0.89, 95% CI: 0.73-1.08). LOS were shorter in the IN-group [-1.26 days, 95% CI: -2.40 to -0.10)]. CONCLUSION: The preoperative use of immunonutrition before major oncologic digestive surgery was not associated with any significant difference in morbidity or mortality. However, the LOS was significantly shorter in the IN-group.

Natural History of Adjustable Gastric Banding: Lifespan and Revisional Rate: A Nationwide Study on Administrative Data on 53,000 Patients.

OBJECTIVE: The aim of this study was to analyze the adjustable gastric banding (AGB) natural history on a national basis. BACKGROUND: Adjustable gastric banding represented the most common bariatric procedure in France until 2010. Since then, the number of AGBs has decreased and the rate of band removal and revisional surgeries has progressively increased. METHODS: For analysis, we included all adult patients operated on with AGB in France between 2007 and 2013. Data were extracted from a national administrative database ("Programme De Médicalisation des Systèmes d'Information," PMSI), which is an exhaustive source of all surgical procedures performed in France. The Cox proportional hazard model was used to test univariate and multivariate associations with band survival and revisional rate. To control for center-specific effects, we performed a frailty analysis, in which each center was assumed to have a random effect indicating the possibility of different baseline risks for patients at different centers. RESULTS: During the study period, 52,868 patients underwent AGB, and 10,815 bands were removed. The removal rate at 5, 6, and 7 years was 28%, 34%, and 40%, respectively. Female sex, body mass index >50 kg/m, type 2 diabetes, hypertension, dyslipidemia, and sleep apnea were found to be significantly associated with band removal by multivariate analysis. A significant center effect was also found, but this did not change the impact of the highly significant factors already identified. After band removal, the median time to revisional surgery was 1 year (95% confidence interval 1.0-1.1) and the conversion rate at 7 years was 71%. CONCLUSIONS: With a removal rate of about 6% annually and the need for revisional surgery for more than two-thirds of patients after removal, AGB does not appear to provide a long-term solution for obesity.

Impact of interhospital competition on mortality of patients operated on for colorectal cancer faced to hospital volume and rurality: A cross-sectional study.

INTRODUCTION: Contradictions remain on the impact of interhospital competition on the quality of care, mainly the mortality. The aim of the study is to evaluate the impact of interhospital competition on postoperative mortality after surgery for colorectal cancer in France. METHODS: We conducted a retrospective cross-sectional study from 2015 to 2019. Data were collected from a National Health Database. Patients operated on for colorectal cancer in a hospital in mainland France were included. Competition was measured using number of competitors by distance-based approach. A mixed-effect model was carried out to test the link between competition and mortality. RESULTS: Ninety-five percent (n = 152,235) of the 160,909 people operated on for colorectal cancer were included in our study. The mean age of patients was 70.4 ±12.2 years old, and female were more represented (55%). A total of 726 hospitals met the criteria for inclusion in our study. Mortality at 30 days was 3.6% and we found that the mortality decreases with increasing of the hospital activity. Using the number of competitors per distance method, our study showed that a "highly competitive" and "moderately competitive" markets decreased mortality by 31% [OR: 0.69 (0.59, 0.80); p<0.001] and by 12% respectively [OR: 0.88 (0.79, 0.99); p<0.03], compared to the "non-competitive" market. High hospital volume (100> per year) was also associated to lower mortality rate [OR: 0.74 (0.63, 0.86); p<0.001]. CONCLUSIONS: The results of our studies show that increasing hospital competition independently decreases the 30-day mortality rate after colorectal cancer surgery. Hospital caseload, patients' characteristics and age also impact the post-operative mortality.

Impact of the thresholds of surgical volume on mortality in oncological digestive surgery: A French National Cohort.

OBJECTIVE: To report the 90-day mortality benefit associated with the implementation of the new regulatory reform on oncological surgical digestive authorizations. SUMMARY BACKGROUND DATA: New thresholds in digestive cancer surgery were applied in 2023, accrediting centers for major interventions. No evidence has been provided to support their justification. METHODS: Any French adult operated for digestive cancer from January 1, 2019 to December 31, 2021 was included from the PMSI. A 90-day mortality logistic regression was performed by adjusting by age, sex, Charlson score, Frailty index, hospital-volume (<5 or ≥5 interventions/year), emergency intervention, specialty. RESULTS: 143,582 patients were identified. Of these, 64,268 underwent surgery of one of the subspecialties subject to the new thresholds (stomach N = 8283, liver N = 18,668, pancreas N = 11,220, esophagus N = 3704, rectum N = 22,393). 4808 (7.5 %) patients underwent surgery in low-volume centers, distributed as follows: stomach 1757/8283 (22.94 %), liver 970/18,668 (5.19 %), pancreas 895/11,220 (7.98 %), esophagus 672/3704 (18.14 %) and rectum 514/22,393 (2.29 %). In univariate analysis, the 90-day mortality rate was significantly lower in high-volume centers, for all subspecialties, gastric: 127/1757 (7.23 %) vs 330/6526 (5.06 %), p = 0.0004, hepatic: 64/970 (6.6 %) vs 824/17,698 (4.66 %), p = 0.006, pancreatic: 74/895 (8, 27 %) vs 608/10,325 (5.89 %), p = 0.004, esophageal: 58/672 (8.63 %) vs 195/3032 (6.43 %), p = 0.04, rectal 26/514 (5.06 %) vs 639/21,879 (2.92 %), p = 0.005. The multivariate analysis, showed a mortality reduction for high-volume centers: OR = 0.78 CI95[0.71-0.87], p < 0.001. CONCLUSION: The recent implementation of regulatory decrees appears to be justified. The enforcement of these hospital volume thresholds is likely to contribute to a reduction in postoperative mortality following digestive cancer surgery.

Patient experience in bariatric surgery: protocol of a French narrative inquiry and qualitative analysis.

INTRODUCTION: The quality of hospital care, especially surgery, is traditionally assessed using indicators derived from healthcare databases or safety indicators. Given the growing importance of placing the patient at the heart of care evaluation, the use of questionnaires such as the Patient-Reported Experience Measures and Patient-Reported Outcome Measures has become widespread in recent years. However, these tools-addressing factors such as satisfaction, pain management or wait times-only imperfectly reflect the patient's experience, and all such attempts at patient-centred care quality assessment rely on questions or indicators defined in advance by healthcare providers and health authorities. A biopsychosocial model may allow to better understand the patient experience and to improve care pathways. This study seeks to construct a narrative of the bariatric surgical care journey with instruments from narrative inquiry, propose a metanarrative that can serve as a basis for more sophisticated and reliable patient-focused care quality models and define indicators linked to patients' feelings and stories. METHODS AND ANALYSIS: To achieve these aims, 16 bariatric surgical patients at the hospital of Créteil, France (Centre Hospitalier Intercommunal de Créteil), will be included and interviewed once before and twice after surgery, at months 3 and 6. Narratives collected will be used to construct a metanarrative intended to encompass all possible narratives. This metanarrative may ultimately inform new patient care quality indicators, furthering care focused on patients and tailored to their needs and predispositions. ETHICS AND DISSEMINATION: The study is funded by the Group of Clinical Research and Innovation in Île-de-France and was approved by CPP SUD-EST VI Clermont-Ferrand (France) Research Ethics Committee. The results will be submitted for publication in peer-reviewed journals. The patient associations will be approached for the dissemination of the study results. TRIAL REGISTRATION NUMBER: NCT05092659.

MIRO study: Do the results of a randomized controlled trial apply in a real population?

BACKGROUND: The aim of our study was to evaluate the external validity of the MIRO randomized controlled trial findings in a similar nationwide setting "real life" population, especially the benefit of a hybrid approach in esophageal resection for pulmonary complication. The external validity of randomized controlled trial findings to the general population with the same condition remains problematic because of the inherent selection bias and rigid inclusion criteria. METHODS: This study was a cohort study from a National Health Database (Programme de Medicalisation des Systemes d'Informations) between 2010 and 2022. All adult patients operated on using Ivor Lewis resection for esophageal cancer were included. We first validated the detection algorithm of postoperative complications in the health database. Then, we assessed the primary outcome, which was the comparison of postoperative severe pulmonary complications, leak rate, and 30-day mortality between the 2 surgical approaches (hybrid versus open) over a decade. RESULTS: Between 2010 and 2012, 162 of 205 patients in the MIRO trial were anonymously identified in the health care database. No difference between randomized controlled trials and healthcare database measurements was found within severe respiratory complications (24% vs 22%, respectively) nor within leak rate (10% vs 9%, respectively). After application of selection criteria according to the MIRO trial, 3,852 patients were included between 2013 and 2022. The hybrid approach was a protective factor against respiratory complications after adjustment for confounding variables (odds ratio = 0.83; 95% confidence interval = 0.71-0.98, P = .025). No significant difference in the 30-day mortality rate or 30-day leakage rate between the types of approach was reported. CONCLUSION: This national cohort study demonstrates the external validity of the MIRO randomized controlled trial findings in a real-life population within France.

Unique Changes in the Incidence of Acute Chest Syndrome in Children With Sickle Cell Disease Unravel the Role of Respiratory Pathogens: A Time Series Analysis.

BACKGROUND: Acute chest syndrome (ACS) is a life-threatening complication of sickle cell disease (SCD). Although respiratory pathogens are frequently detected in children with ACS, their respective role in triggering the disease is still unclear. We hypothesized that the incidence of ACS followed the unprecedented population-level changes in respiratory pathogen dynamics after COVID-19-related nonpharmaceutical interventions (NPIs). RESEARCH QUESTION: What is the respective role of respiratory pathogens in ACS epidemiology? STUDY DESIGN AND METHODS: This study was an interrupted time series analysis of patient records from a national hospital-based surveillance system. All children aged < 18 years with SCD hospitalized for ACS in France between January 2015 and May 2022 were included. The monthly incidence of ACS per 1,000 children with SCD over time was analyzed by using a quasi-Poisson regression model. The circulation of 12 respiratory pathogens in the general pediatric population over the same period was included in the model to assess the fraction of ACS potentially attributable to each respiratory pathogen. RESULTS: Among the 55,941 hospitalizations of children with SCD, 2,306 episodes of ACS were included (median [interquartile range] age, 9 [5-13] years). A significant decrease was observed in ACS incidence after NPI implementation in March 2020 (-29.5%; 95% CI, -46.8 to -12.2; P = .001) and a significant increase after lifting of the NPIs in April 2021 (24.4%; 95% CI, 7.2 to 41.6; P = .007). Using population-level incidence of several respiratory pathogens, Streptococcus pneumoniae accounted for 30.9% (95% CI, 4.9 to 56.9; P = .02) of ACS incidence over the study period and influenza 6.8% (95% CI, 2.3 to 11.3; P = .004); other respiratory pathogens had only a minor role. INTERPRETATION: NPIs were associated with significant changes in ACS incidence concomitantly with major changes in the circulation of several respiratory pathogens in the general population. This unique epidemiologic situation allowed determination of the contribution of these respiratory pathogens, in particular S pneumoniae and influenza, to the burden of childhood ACS, highlighting the potential benefit of vaccine prevention in this vulnerable population.

Clinical care pathways of patients with biliary tract cancer: A French nationwide longitudinal cohort study.

BACKGROUND: Although the incidence of BTC is raising, national healthcare strategies to improve care lack. We aimed to explore patient clinical care pathways and strategies to improve biliary tract cancer (BTC) care. METHODS: We analysed the French National Healthcare database of all BTC inpatients between January 1, 2017 and December 31, 2021. Multinomial logistic regression adjusted odds ratios (aOR) were used to identify healthcare organisation factors that influenced access to curative care both overall and in a longitudinal sensibility analysis using optimal matching and hierarchical ascending classification to detect a subgroup of curative-care patients with a high survival over a two-year period. RESULTS: A total of 19,825 new BTC patients and three clinical care pathways (CCP) were identified: 'Palliative care' (PC-CCP), 'Non-curative Care' (NCC-CCP) and 'Curative Care' (CC-CCP) involving 7669 (38.7%), 7721 (38.9%) and 4435 (22.4%) patients respectively. Out of 1200 centers involved in BTC treatment, 84%, 11% and 5% were of low- (<15 patients/year), medium- (15-30 patients/year) and high-volume (>30 patients/year) respectively. Among patient, tumor and hospital factors, BTC management in academic (aOR: 2.32; 95%CI: 1.98-2.71), private (2.51; 2.22-2.83), semi-private (2.25; 1.91-2.65) and in high- (2.09; 1.81-2.42) or medium-volume (1.49; 1.33-1.68) centers increased probability to CC-CCP. These results were maintained in a longitudinal cluster of 2363 (53%) CC-CCP patients presenting a higher two-year survival compared with the rest [96.4% (95.1; 97.6) vs. 38.8% (36.3; 41.4), log-rank p < 0.001]. CONCLUSIONS: Among factors subject to healthcare policy improvement, the volume and type of centers managing BTC strongly influenced access to curative care.

Risk of Esophageal and Gastric Cancer After Bariatric Surgery.

Importance: Bariatric surgery has been associated with a reduced risk of cancer in individuals with obesity. The association of bariatric surgery with esophageal and gastric cancer is still controversial, however. Objective: To compare the incidence of esophageal and gastric cancer between patients with obesity who underwent bariatric surgery and those who did not (control group). Design, Setting, and Participants: This cohort study obtained data from a national discharge database, including all surgical centers, in France from January 1, 2010, to December 31, 2017. Participants included adults (aged ≥18 years) with severe obesity who underwent bariatric surgery (surgical group) or who did not (control group). Baseline characteristics were balanced between groups using nearest neighbor propensity score matching with a 1:2 ratio. The study was conducted from March 1, 2020, to June 30, 2021. Exposures: Bariatric surgery (adjustable gastric banding, gastric bypass, and sleeve gastrectomy) vs no surgery. Main Outcomes and Measures: The main outcome was incidence of esophageal and gastric cancer. A secondary outcome was overall in-hospital mortality. Results: A total of 303 709 patients who underwent bariatric surgery (245 819 females [80.9%]; mean [SD] age, 40.2 [11.9] years) were matched 1:2 with 605 140 patients who did not receive surgery (500 929 females [82.8%]; mean [SD] age, 40.4 [12.5] years). After matching, the 2 groups of patients were comparable in terms of age, sex, and comorbidities (standardized mean difference [SD], 0.05 [0.11]), with some differences in body mass index. The mean follow-up time was 5.62 (2.20) years in the control group and 6.06 (2.31) years in the surgical group. A total of 337 patients had esophagogastric cancer: 83 in the surgical group and 254 in the control group. The incidence rates were 6.9 per 100 000 population per year for the control group and 4.9 per 100 000 population per year for the surgical group, resulting in an incidence rate ratio of 1.42 (95% CI, 1.11-1.82; P = .005). The hazard ratio (HR) of cancer incidence was significantly in favor of the surgical group (HR, 0.76; 95% CI, 0.59-0.98; P = .03). Overall mortality was significantly lower in the surgical group (HR, 0.60; 95% CI, 0.56-0.64; P < .001). Conclusions and Relevance: In this large, nationwide cohort of patients with severe obesity, bariatric surgery was associated with a significant reduction of esophageal and gastric cancer incidence and overall in-hospital mortality, which suggests that bariatric surgery can be performed as treatment for severe obesity without increasing the risk of esophageal and gastric cancer.

Preoperative Follow-up in Bariatric Surgery: Why They Give Up? Rate, Causes, and Economic Impact of Dropout.

BACKGROUND: Preoperative attrition is highly prevalent in patients referred for bariatric surgery. Little information is available neither on reasons reported by patients for attrition in knowledge nor costs of attrition in a publicly funded health system. OBJECTIVES: To assess the reasons for the attrition of bariatric candidates and calculate its economic impact on a population with obesity in a public hospital in France. METHODS: This is a retrospective study including all bariatric surgery candidates between 2014 and 2018 in our Center of Excellence in Obesity Care. Data were extracted from the hospital information system, and patient-related outcomes were collected via a standardized questionnaire. Economic analysis was performed. Primary outcome was to analyze the rate of preoperative attrition. Secondary outcome was reasons for discontinuation and their economic impact. RESULTS: In total, 1360 patients were referred for bariatric surgery at our hospital, and 1225 were included in the study. Attrition rate in preoperative phase was 46.8%. Three factors were significantly associated with follow-up fragmentation risk: unemployment (OR 0.52, 95% CI 0.29-0.7, p < 0.001), active smoking (OR 2.24, 95% CI 1.53-5.15, p < 0.001), and body mass index (OR 0.98, 95% CI 0.97-1.00, p = 0.036). Average cost to the healthcare system was €792 for each patient who dropped out. CONCLUSIONS: We identified predictors and patient-reported factors that seem to be beyond the possibility of removal by health professionals. We should consider and address preventable factors, through the development of care pathways tailored to the individual profile of a patient.

Outcomes Associated With Caustic Ingestion Among Adults in a National Prospective Database in France.

Importance: Caustic ingestion in adults may result in death or severe digestive sequelae. The scarcity of nationwide epidemiological data leads to difficulties regarding the applicability of their analysis to less specialized centers, which are nevertheless largely involved in the emergency management of adverse outcomes following caustic ingestion. Objective: To assess outcomes associated with caustic ingestion in adults across a nationwide prospective database. Design, Settings, and Participants: Adult patients aged 16 to 96 admitted to the emergency department for caustic ingestion between January 2010 and December 2019 were identified from the French Medical Information System Database, which includes all patients admitted in an emergency setting in hospitals in France during this period. Exposure: Esophageal caustic ingestion. Main Outcomes and Measures: The primary end point was in-hospital patient outcomes following caustic ingestion. Multivariate analysis was performed to assess independent predictors of in-hospital morbidity and mortality. Results: Among 22 657 226 patients admitted on an emergency outpatient basis, 3544 (0.016%) had ingested caustic agents and were included in this study. The median (IQR) age in this population was 49 (34-63) years, and 1685 patients (48%) were women. Digestive necrosis requiring resection was present during the primary hospital stay in 388 patients with caustic ingestion (11%). Nonsurgical management was undertaken in 3156 (89%). A total of 1198 (34%) experienced complications, and 294 (8%) died. Pulmonary complications were the most frequent adverse event, occurring in 869 patients (24%). On multivariate analysis, predictors of mortality included old age, high comorbidity score, suicidal ingestion, intensive care unit admission during management, emergency surgery for digestive necrosis, and treatment in low-volume centers. On multivariate analysis, predictors of morbidity included old age, higher comorbidity score, intensive care unit admission during management, and emergency surgery for digestive necrosis. Conclusions and Relevance: In this study, referral to expert centers was associated with improved early survival after caustic ingestion. If feasible, low-volume hospitals should consider transferring patients to larger centers instead of attempting on-site management.

Clinical and Economic Impact of Previous Bariatric Surgery on Liver Transplantation: a Nationwide, Population-Based Retrospective Study.

PURPOSE: The present study aims to determine the impact of previous bariatric surgery (BS) on the length of hospital stay; the incidence of mortality, re-transplantation, and re-hospitalization after LT; and the related economic costs, through the analysis of the French National Health Insurance Information System. MATERIALS AND METHODS: All patients aged > 18 years who underwent LT in France in the period from 2010 to 2019 were included. Thirty-nine patients with a history of BS (study group) were compared with 1798 obese patients without previous BS (control group). RESULTS: At the time of LT, patients with a history of BS were significantly younger than those of the control group and had lower Charlson comorbidity index. Female sex was significantly more represented in the study group. No significant differences were detected between the two groups regarding the postoperative mortality rate after LT (10.3% in the study group versus 8.0% in the control group), long-term mortality (0.038 versus 0.029 person-year of follow-up, respectively), re-transplantation (adjusted hazard ratio (HR) = 2.15, p = 0.2437), re-hospitalization (adjusted analysis, IRR = 0.93, p = 0.7517), and costs of LT hospitalization (73,515 € in the study group versus 65,878 € in the control group). After 1:2 propensity score matching, the duration of the LT hospital stay was significantly longer in the study group (58.3 versus 33.4 days, p = 0.0172). CONCLUSION: No significant differences were detected between patients with previous BS versus obese patients without history of BS undergoing LT concerning the rates of mortality, re-LT, re-hospitalization after LT, and costs of hospitalization and re-hospitalizations.

Incidence of Acute Chest Syndrome in Children With Sickle Cell Disease Following Implementation of the 13-Valent Pneumococcal Conjugate Vaccine in France.

Importance: Acute chest syndrome (ACS) is one of the leading acute severe complications of sickle-cell disease (SCD). Although Streptococcus pneumoniae (S pneumoniae) is highly prevalent in children with SCD, its precise role in ACS is unclear. The efficacy of 13-valent pneumococcal conjugate vaccine (PCV13) implementation on ACS is still unknown. Objective: To assess the association of PCV13 implementation in the general pediatric population with the incidence of ACS in children with SCD. Design, Setting, and Participants: This cohort study used an interrupted time-series analysis of patient records from a national hospital-based French surveillance system. All children younger than 18 years with SCD (based on the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision definition) hospitalized in France between January 2007 and December 2019 were included. Exposures: PCV13 implementation. Main Outcomes and Measures: Monthly incidence of ACS per 1000 children with SCD over time as analyzed by segmented linear regression with autoregressive error; monthly incidence of hospitalization for vaso-occlusive crisis, asthma crisis, and acute pyelonephritis per 1000 children with SCD over the same period as the control outcomes. Results: Among the 107 694 hospitalizations of children with SCD, 4007 episodes of ACS were included (median [IQR] age, 8 [4-12] years; 2228 [55.6%] boys). PCV13 implementation in 2010 was followed by a significant decrease in the incidence of ACS (-0.9% per month; 95% CI, -1.4% to -0.4%; P < .001), with an estimated cumulative change of -41.8% (95% CI, -70.8% to -12.7%) by 2019. Sensitivity analyses yielded the same results, including the incidence of ACS adjusted for that of vaso-occlusive crisis over time. The results were similar among different age groups. By contrast, no change was found for the 3 control outcomes over the study period. Conclusions and Relevance: PCV13 implementation was associated with an important reduction in the incidence of ACS in children with SCD. This vaccine benefit provides new evidence of the key role of S pneumoniae in ACS and should be considered when estimating outcomes associated with current PCVs and the potential benefit of next-generation PCVs in children.

Association of Nonpharmaceutical Interventions During the COVID-19 Pandemic With Invasive Pneumococcal Disease, Pneumococcal Carriage, and Respiratory Viral Infections Among Children in France.

Importance: An association between pneumococcal nasopharyngeal carriage and invasive pneumococcal disease (IPD) has been previously established. However, it is unclear whether the decrease in IPD incidence observed after implementation of nonpharmaceutical interventions (NPIs) during the COVID-19 pandemic was associated with concomitant changes in pneumococcal carriage and respiratory viral infections. Objective: To assess changes in IPD incidence after the implementation of NPIs during the COVID-19 pandemic and examine their temporal association with changes in pneumococcal carriage rate and respiratory viral infections (specifically respiratory syncytial virus [RSV] and influenza cases) among children in France. Design, Setting, and Participants: This cohort study used interrupted time series analysis of data from ambulatory and hospital-based national continuous surveillance systems of pneumococcal carriage, RSV and influenza-related diseases, and IPD between January 1, 2007, and March 31, 2021. Participants included 11 944 children younger than 15 years in France. Exposures: Implementation of NPIs during the COVID-19 pandemic. Main Outcomes and Measures: The estimated fraction of IPD change after implementation of NPIs and the association of this change with concomitant changes in pneumococcal carriage rate and RSV and influenza cases among children younger than 15 years. The estimated fraction of change was analyzed using a quasi-Poisson regression model. Results: During the study period, 5113 children (median [IQR] age, 1.0 [0.6-4.0] years; 2959 boys [57.9%]) had IPD, and 6831 healthy children (median [IQR] age, 1.5 [0.9-3.9] years; 3534 boys [51.7%]) received a swab test. Data on race and ethnicity were not collected. After NPI implementation, IPD incidence decreased by 63% (95% CI, -82% to -43%; P < .001) and was similar for non-13-valent pneumococcal conjugate vaccine serotypes with both high disease potential (-63%; 95% CI, -77% to -48%; P < .001) and low disease potential (-53%; 95% CI, -70% to -35%; P < .001). The overall pneumococcal carriage rate did not significantly change after NPI implementation (-12%; 95% CI, -37% to 12%; P = .32), nor did the carriage rate for non-PCV13 serotypes with high disease potential (-26%; 95% CI, -100% to 52%; P = .50) or low disease potential (-7%; 95% CI, -34% to 20%; P = .61). After NPI implementation, the estimated number of influenza cases decreased by 91% (95% CI, -74% to -97%; P < .001), and the estimated number of RSV cases decreased by 74% (95% CI, -55% to -85%; P < .001). Overall, the decrease in influenza and RSV cases accounted for 53% (95% CI, -28% to -78%; P < .001) and 40% (95% CI, -15% to -65%; P = .002) of the decrease in IPD incidence during the NPI period, respectively. The decrease in IPD incidence was not associated with pneumococcal carriage, with carriage accounting for only 4% (95% CI, -7% to 15%; P = .49) of the decrease. Conclusions and Relevance: In this cohort study of data from multiple national continuous surveillance systems, a decrease in pediatric IPD incidence occurred after the implementation of NPIs in France; this decrease was associated with a decrease in viral infection cases rather than pneumococcal carriage rate. The association between pneumococcal carriage and IPD was potentially modified by changes in the number of RSV and influenza cases, suggesting that interventions targeting respiratory viruses, such as immunoprophylaxis or vaccines for RSV and influenza, may be able to prevent a large proportion of pediatric IPD cases.