Epidemiology of congenital heart defects in France from 2013 to 2022 using the PMSI-MCO (French Medical Information System Program in Medicine, Surgery, and Obstetrics) database.

BACKGROUND: Congenital heart defects are common and occur in approximately 0.9% of births. In France, the registries cover approximately 20% of the population but not the entirety of France; therefore, we aimed to update the incidence data for congenital heart defects in France from 2013 to 2022 using the medico-administrative database PMSI-MCO (French Medical Information System Program in Medicine, Surgery, and Obstetrics). We aimed to compare the frequency of risk factors in a population with congenital heart defects and a reference population. METHODS: From 2013 to 2022, we included children aged < 3 years diagnosed with congenital heart defects according to the International Classification of Diseases, 10th Revision, in the PMSI-MCO database. We compared them with a population without congenital defects on several medical data items (e.g., parity, gemellarity, and mortality rate). Bivariate and multivariate analyses compared children with congenital heart defects and children without congenital malformation. RESULTS: We identified 83,879 children with congenital heart defects in France from 2013 to 2022 in the PMSI-MCO database and 7,739,840 children without such defects, including 7,218,952 without any congenital defects. We observed more deaths (7.49% vs. 0.68%, d = 0.59) and more twinning (8.67% vs. 1.23%, d = 0.35) among children with congenital heart defects. Multivariate analysis revealed an increased risk of congenital heart defects in male individuals (OR [odds ratio] 1.056, 95% CI [confidence interval] [1.039-1.076]) and cases of medically assisted reproduction (OR 1.115, 95% CI [1.045-1.189]) and a reduced risk in the case of multiparity (OR 0.921, 95% CI [0.905-0.938]). CONCLUSIONS: According to the PMSI-MCO database, the incidence of congenital heart defects in France from 2013 to 2022 is 1% of births. Congenital heart defects are more frequent in cases of prematurity, twinning, primiparity, male sex, and maternal age > 40 years.

Should Cytoreductive Surgery Alone for Peritoneal Metastases of Colorectal Origin be Centralized? A National Study of 4159 Procedures.

BACKGROUND: Addition of oxaliplatin-based hyperthermic intraperitoneal chemotherapy (HIPEC) to cytoreductive surgery (CRS) in the treatment of peritoneal metastases of colorectal origin (CRPM) did not show any survival benefit in the PRODIGE 7 trial (P7). This study aimed to investigate whether perioperative outcomes after CRS alone for CRPM patients is mediated by hospital volume and to determine the effect of P7 on French practice for CRPM patients treated respectively with CRS alone and CRS/HIPEC. METHODS: Data from CRPM patients treated with CRS alone between 2013 and 2020 in France were collected through a national medical database. The study used a cutoff value of the annual CRS-alone caseload affecting the 90-day postoperative mortality (POM) determined from our previous study to define low-volume (LV) HIPEC and high-volume (HV) HIPEC centers. Perioperative outcomes were compared between no-HIPEC, LV-HIPEC, and HV-HIPEC centers. The trend between years and HIPEC rates was analyzed using the Cochrane-Armitage test. RESULTS: Data from 4159 procedures were analyzed. The patients treated in no-HIPEC and LV-HIPEC centers were older compared with HV-HIPEC centers (p < 0.0001) and had a higher Elixhauser comorbidity index (p < 0.0001) and less complex surgery (p < 0.0001). Whereas the major morbidity (MM) rate did not differ between groups (p = 0.79), the 90-day POM was lower in HV-HIPEC centers than in no-HIPEC and LV-HIPEC centers (5.4% vs 15% and 13.3%; p < 0.0001), with lower failure-to-rescue (FTR) (p < 0.0001). After P7, the CRS/HIPEC rate decreased drastically in Cancer centers (p < 0.001), whereas patients treated with CRS alone are still referred to expert centers. CONCLUSIONS: Centralization of CRS alone should improve patient selection as well as FTR and POM. After P7, CRS/HIPEC decreased mostly in Cancer centers, without any impact on the number of CRS-alone cases referred to expert centers.

Hospital surgical volume-outcome relationship of postoperative morbidity for ileocolic resection in Crohn's disease: A French nationwide study of 4,205 patients.

BACKGROUND AND AIMS: Despite the development of medical therapy, nearly 50% of patients with Crohn's disease (CD) undergo surgery during their lifetime. Several studies have suggested some risk factors for postoperative morbidity (POM) after ileocolic resection (ICR). However, the impact of surgical hospital volume on POM in CD has not been extensively studied. This study aimed to assess the impact of surgical hospital volume on POM after ICR for CD. METHODS: All patients with CD who underwent ICR in France between 2013 and 2022 were identified in the French Database, Programme de Médicalisation des Systèmes d'Information. Using the Chi-square automatic interaction detector, we determined the cut-off value to split high-surgical volume (≥6 ICR/year) and low-surgical volume centers (<6 ICR/year). The primary outcome was the evaluation of major POM during hospitalization. POM was evaluated according to the surgical volume center. The Elixhauser comorbidity index (ECI) was used to categorize the comorbidities of patients. RESULTS: A total of 4,205 patients were identified, and the major POM during hospitalization was significantly (p = 0.0004) lower in the high-surgical volume (6.2%) compared to low-surgical volume centers (9.1%). After multivariate analysis, independent factors associated with major POM were surgical hospital volume (P = 0.024), male sex (P = 0.029), ECI ≥1 (P < 0.001), and minor POM (P < 0.001). CONCLUSION: Major POM after ICR for CD is closely associated with surgical hospital volume. Centralization of surgery for CD is desirable, especially in patients with major comorbidities.

Study of Risk Factors for Readmission After Pancreatectomy for Cancer: Analysis of Nationwide Cohort.

OBJECTIVE: To identify the factors associated with readmission after pancreatectomy for cancer and to assess their impact on the 1-year mortality in a French multicentric population. BACKGROUND: Pancreatectomy is a complex procedure with high morbidity that increases the length of hospital stay and jeopardizes survival. Hospital readmissions lead to increased health system costs, making this a topic of great interest. METHODS: Data collected from patients who underwent pancreatectomy for cancer between 2011 and 2019 were extracted from a French national medico-administrative database. A descriptive analysis was conducted to evaluate the association of baseline variables, including age, sex, liver-related comorbidities, Charlson Comorbidity Index, tumor localization, and use of neoadjuvant therapy, along with hospital type and volume, with readmission status. Centers were divided into low and high volumes according to the cutoff of 26 cases/year. Logistic regression models were developed to determine whether the identified bivariate associations persisted after adjusting for the patient characteristics. The mortality rates during readmission and at 1 year postoperatively were also determined. RESULTS: Of 22,935 patients who underwent pancreatectomy, 9129 (39.3%) were readmitted within 6 months. Readmission rates by year did not vary over the study period, and mean readmissions occurred within 20 days after discharge. Multivariate analysis showed that male sex [odds ratio (OR) = 1.12], age >70 years (OR = 1.16), comorbidities (OR = 1.21), distal pancreatectomy (OR = 1.11), and major postoperative complications (OR = 1.37) were predictors of readmission. Interestingly, readmission and surgery in low-volume centers increased the risk of death at 1 year by a factor of 2.15 [(2.01-2.31), P < 0.001] and 1.31 [(1.17-1.47), P < 0.001], respectively. CONCLUSIONS: Readmission after pancreatectomy for cancer is high with an increased rate of 1-year mortality.

Intraoperative Mechanical Power and Postoperative Pulmonary Complications in Noncardiothoracic Elective Surgery Patients: A 10-Year Retrospective Cohort Study.

BACKGROUND: Postoperative pulmonary complications is a major issue that affects outcomes of surgical patients. The hypothesis was that the intraoperative ventilation parameters are associated with occurrence of postoperative pulmonary complications. METHODS: A single-center retrospective cohort study was conducted at the Lille University Hospital, France. The study included 33,701 adults undergoing noncardiac, nonthoracic elective surgery requiring general anesthesia with tracheal intubation between January 2010 and December 2019. Intraoperative ventilation parameters were compared between patients with and without one or more postoperative pulmonary complications (respiratory infection, respiratory failure, pleural effusion, atelectasis, pneumothorax, bronchospasm, and aspiration pneumonitis) within 7 days of surgery. RESULTS: Among 33,701 patients, 2,033 (6.0%) had one or more postoperative pulmonary complications. The lower tidal volume to predicted body weight ratio (odds ratio per -1 ml·kgPBW-1, 1.08; 95% CI, 1.02 to 1.14; P < 0.001), higher mechanical power (odds ratio per 4 J·min-1, 1.37; 95% CI, 1.26 to 1.49; P < 0.001), dynamic respiratory system compliance less than 30 ml·cm H2O (1.30; 95% CI, 1.15 to 1.46; P < 0.001), oxygen saturation measured by pulse oximetry less than 96% (odds ratio, 2.42; 95% CI, 1.97 to 2.96; P < 0.001), and lower end-tidal carbon dioxide (odds ratio per -3 mmHg, 1.06; 95% CI, 1.00 to 1.13; P = 0.023) were independently associated with postoperative pulmonary complications. Patients with postoperative pulmonary complications were more likely to be admitted to the intensive care unit (odds ratio, 12.5; 95% CI, 6.6 to 10.1; P < 0.001), had longer hospital length of stay (subhazard ratio, 0.43; 95% CI, 0.40 to 0.45), and higher in-hospital (subhazard ratio, 6.0; 95% CI, 4.1 to 9.0; P < 0.001) and 1-yr mortality (subhazard ratio, 2.65; 95% CI, 2.33 to 3.02; P < 0.001). CONCLUSIONS: In the study's population, decreased rather than increased tidal volume, decreased compliance, increased mechanical power, and decreased end-tidal carbon dioxide were independently associated with postoperative pulmonary complications.

Outcomes Associated With Esophageal Perforation Management: Results From a French Nationwide Population-based Cohort Study.

OBJECTIVE: To evaluate outcomes associated with esophageal perforation (EP) management at a national level and determine predictive factors of 90-day mortality (90dM), failure-to-rescue (FTR), and major morbidity (MM, Clavien-Dindo 3-4). BACKGROUND: EP remains a challenging clinical emergency. Previous population-based studies showed rates of 90dM up to 38.8% but were outdated or small-sized. METHODS: Data from patients admitted to hospitals with EP were extracted from the French medico-administrative database (2012-2021). Etiology, management strategies, and short and long-term outcomes were analyzed. A cutoff value of the annual EP management caseload affecting FTR was determined using the "Chi-squared Automatic Interaction Detector" method. Random effects logistic regression model was performed to assess independent predictors of 90dM, FTR, and MM. RESULTS: Among 4765 patients with EP, 90dM and FTR rates were 28.0% and 19.4%, respectively. Both remained stable during the study period. EP was spontaneous in 68.2%, due to esophageal cancer in 19.7%, iatrogenic postendoscopy in 7.3%, and due to foreign body ingestion in 4.7%. Primary management consisted of surgery (n = 1447,30.4%), endoscopy (n = 590,12.4%), isolated drainage (n = 336,7.0%), and conservative management (n = 2392,50.2%). After multivariate analysis, besides age and comorbidity, esophageal cancer was predictive of both 90dM and FTR. An annual threshold of ≥8 EP managed annually was associated with a reduced 90dM and FTR rate. In France, only some university hospitals fulfilled this condition. Furthermore, primary surgery was associated with a lower 90dDM and FTR rate despite an increase in MM. CONCLUSIONS: We provide evidence for the referral of EP to high-volume centers with multidisciplinary expertise. Surgery remains an effective treatment for EP.

Risk-Benefit Balance of Simultaneous Gastric Bypass or Sleeve Gastrectomy and Concomitant Cholecystectomy: A Comprehensive Nationwide Cohort of 289,627 Patients.

OBJECTIVE: To assess the relevance of concomitant laparoscopic metabolic bariatric surgery (MBS) and cholecystectomy. BACKGROUND: Because of the massive weight loss it induces, MBS is associated with an increase in the frequency of gallstones. However, no consensus yet exists on the risk-to-benefit ratio of a concomitant cholecystectomy (CC) during MBS to prevent long-term biliary complications. METHODS: This nationwide retrospective cohort research was conducted in 2 parts using information from a national administrative database (PMSI). The 90-day morbidity of MBS with or without CC was first compared in a matched trial (propensity score). Second, we observed medium-term biliary complication following MBS when no CC had been performed during MBS up to 9 years after MBS (minimum 18 months). RESULTS: Between 2013 and 2020, 289,627 patients had a sleeve gastrectomy (SG: 70%) or a gastric bypass (GBP: 30%). The principal indications of CC were symptomatic cholelithiasis (79.5%) or acute cholecystitis (3.6%). Prophylactic CC occurred only in 15.5% of the cases. In our matched-group analysis, we included 9323 patients in each arm. The complication rate at day 90 after surgery was greater in the CC arm [odds ratio=1.3 (1.2-1.5), P <0.001], independently of the reason of the CC. At 18 months, there was a 0.1% risk of symptomatic gallstone migration and a 0.08% risk of biliary pancreatitis. At 9 years, 20.5±0.52% of patients underwent an interval cholecystectomy. The likelihood of interval cholecystectomy decreased from 5.4% per year to 1.7% per year after the first 18 months the whole cohort, risk at 18 months of symptomatic gallstone migration was 0.1%, of pancreatitis 0.08%, and of angiocholitis 0.1%. CONCLUSION: CC during SG and GBP should be avoided. In the case of asymptomatic gallstones after MBS, prophylactic cholecystectomy should not be recommended.

Aortic dissection: results of the invasive treatment in France between 2012 and 2018 according to the French national database.

BACKGROUND: To evaluate results of the invasive repair in the management of acute aortic dissection (AoD) in France. METHODS: Patients admitted to hospital with acute AoD from 2012 to 2018 were identified. Patient demographics, severity score at admission, treatment strategy and in-hospital mortality were described. For patients undergoing intervention, perioperative complications rate was reported. A secondary analysis evaluating patients' outcome as regards of the annual caseload per center was conducted. RESULTS: Overall, 14,706 patients with acute AoD were identified (male 64%, mean age 67, median modified Elixhauser score 5). The overall incidence increased during the study period (from 3.8 in 2012 to 4.4/100,000 in 2018) associated with a North-South gradient (respectively 3.6 vs. 4.7/100,000) and a winter peak; 45.5% (N.=6697) of patients received medical treatment alone. Among those with invasive repair, 6276 (78.3%) were defined as type A AoD (TAAD), whereas type B AoD (TBAD) accounted for 1733 patients (21.7%), of whom 1632 (94%) had TEVAR and 101 (6%) had other arterial procedures; 30-day mortality was respectively 18.9% in TAAD and 9.5% for TBAD. In high-volume centers (i.e. >20 AoD/year), a lower 3-month mortality of 22.3% was noted compared to 31.4% in the low-volume centres (P<0.001); 47% of patients reported ≥1 early major complication. TEVAR exhibited less complication (P<0.001) compared to other arterial reconstructions in TBAD. CONCLUSIONS: The incidence of acute AoD increased in France over the period of the study and was associated with stable postoperative early mortality. Early postoperative mortality is significantly reduced in high-volume centers.

Pre-gestational diabetes and the risk of congenital heart defects in the offspring: A French nationwide study.

AIM: To compare the frequencies and types of congenital heart defects for infants of women without and with pre-gestational diabetes, type 1 and type 2 diabetes (T1DM, T2DM) and to identify risk factors. METHODS: All live births between 2012 and 2020 were screened for maternal diabetes and infant congenital heart defects using the French Medical Information System Program in Medicine, Surgery and Obstetrics database (PMSI-MCO). Incidences of these defects were estimated, and a logistic model evaluated maternal and fetal prognostic risk factors. RESULTS: Overall, 6,038,703 mothers did not have pre-gestational diabetes (no-diabetes), 23,147 had T1DM, and 14,401 had T2DM. The incidence of infant congenital disease was 6.2% for the no-diabetes group, 8.0%, for women with T1DM, and 8.4% for women with T2DM (P < 0.001); for congenital heart defects, incidences were respectively 0.8%, 3.0% and 2.7% (P < 0.001). In comparison with the no-diabetes group, the odds ratios (95%CI) of coronary heart defects were 2.07 (1.91;2.24) (P < 0.001) for women with T1DM and 2.20 (1.99;2.44) (P < 0.001) for women with T2DM, with no difference between T1DM and T2DM (P = 0.336). cesarian section, small and large for gestational age, and prematurity were also associated with an increased risk of congenital heart defects. CONCLUSION: In this study we observed higher incidences of congenital heart defects in infants of women with pre-gestational diabetes compared to women without pre-gestational diabetes, with no difference between women with T1DM or T2DM. These data call for intensifying preconception care and justify systematic cardiac echography in selected fetuses.

Major interregional differences in France of COVID-19 hospitalization and mortality from January to June 2020.

INTRODUCTION: Even though France was severely hit by the COVID-19 pandemic, few studies have addressed the dynamics of the first wave on an exhaustive, nationwide basis. We aimed to describe the geographic and temporal distribution of COVID-19 hospitalisations and in-hospital mortality in France during the first epidemic wave, from January to June 2020. METHODS: This retrospective cohort study used the French national database for all acute care hospital admissions (PMSI). Contiguous stays were assembled into "care sequences" for analysis so as to limit bias when estimating incidence and mortality. The incidence rate and its evolution, mortality and hospitalized case fatality rates (HCFR) were compared between geographic areas. Correlations between incidence, mortality, and HCFR were analyzed. RESULTS: During the first epidemic wave, 98,366 COVID-19 patients were hospitalized (incidence rate of 146.7/100,000 inhabitants), of whom 18.8% died. The median age was 71 years, the male/female ratio was 1.16, and 26.2% of patients required critical care. The Paris area and the North-East region were the first and most severely hit areas. A rapid increase of incidence and mortality within 4 weeks was followed by a slow decrease over 10 weeks. HCFRs decreased during the study period, and correlated positively with incidence and mortality rates. DISCUSSION: By detailing the geographical and temporal evolution of the COVID-19 epidemic in France, this study revealed major interregional differences, which were otherwise undetectable in global analyses. The precision afforded should help to understand the dynamics of future epidemic waves.

Risk factors for admission to the pediatric critical care unit among children hospitalized with COVID-19 in France.

Background: COVID-19 infection is less severe among children than among adults; however, some patients require hospitalization and even critical care. Using data from the French national medico-administrative database, we estimated the risk factors for critical care unit (CCU) admissions among pediatric COVID-19 hospitalizations, the number and characteristics of the cases during the successive waves from January 2020 to August 2021 and described death cases. Methods: We included all children (age < 18) hospitalized with COVID-19 between January 1st, 2020, and August 31st, 2021. Follow-up was until September 30th, 2021 (discharge or death). Contiguous hospital stays were gathered in "care sequences." Four epidemic waves were considered (cut off dates: August 11th 2020, January 1st 2021, and July 4th 2021). We excluded asymptomatic COVID-19 cases, post-COVID-19 diseases, and 1-day-long sequences (except death cases). Risk factors for CCU admission were assessed with a univariable and a multivariable logistic regression model in the entire sample and stratified by age, whether younger than 2. Results: We included 7,485 patients, of whom 1988 (26.6%) were admitted to the CCU. Risk factors for admission to the CCU were being younger than 7 days [OR: 3.71 95% CI (2.56-5.39)], being between 2 and 9 years old [1.19 (1.00-1.41)], pediatric multisystem inflammatory syndrome (PIMS) [7.17 (5.97-8.6)] and respiratory forms [1.26 (1.12-1.41)], and having at least one underlying condition [2.66 (2.36-3.01)]. Among hospitalized children younger than 2 years old, prematurity was a risk factor for CCU admission [1.89 (1.47-2.43)]. The CCU admission rate gradually decreased over the waves (from 31.0 to 17.8%). There were 32 (0.4%) deaths, of which the median age was 6 years (IQR: 177 days-15.5 years). Conclusion: Some children need to be more particularly protected from a severe evolution: newborns younger than 7 days old, children aged from 2 to 13 years who are more at risk of PIMS forms and patients with at least one underlying medical condition.

Effect of Phased Implementation of Totally Minimally Invasive Ivor Lewis Esophagectomy for Esophageal Cancer after Previous Adoption of the Hybrid Minimally Invasive Technique: Results from a French Nationwide Population-Based Cohort Study.

BACKGROUND: Several randomized controlled trials (RCTs) have demonstrated improved short-term outcomes of totally minimally invasive esophagectomy (TMIE) compared with open esophagectomy (OE); however, to what extent these outcomes can be extrapolated to a national level remains debatable. OBJECTIVE: The aim of this study was to evaluate, on a nationwide basis, the short-term outcomes of TMIE and to analyze these results within the context of previously implemented hybrid minimally invasive esophagectomy (HMIE). METHODS: All consecutive patients who underwent a curative Ivor Lewis esophagectomy in France between 2017 and 2019 were included in this retrospective cohort study. The primary endpoint was to compare 90-day postoperative mortality (POM) between OE, HMIE, and TMIE, while secondary endpoints were defined as the rate of postoperative complications. A matched and multivariate analysis was adjusted for confounding factors. RESULTS: Overall, 2675 patients were included (1003 OE vs. 1498 HMIE vs. 174 TMIE). In every center where TMIE was performed, HMIE had been previously adopted. The matched 90-day POM rate in the TMIE group was significantly lower compared with the OE group (2.3% vs. 6.3%, p = 0.046) but not compared with the HMIE group (2.3% vs. 4.9%, p = 0.156). There was no significant difference between TMIE and OE, or TMIE and HMIE, regarding the 30-day fistula rate (21.8% vs. 17%, p = 0.176; and 21.8% vs. 21.3%, p = 0.88, respectively). TMIE was associated with a reduced rate of pulmonary complications compared with OE (33.9% vs. 44%, p = 0.027) and HMIE (33.9% vs. 42.8%, p = 0.05). Low-volume centers were identified as a negative predictive factor for 90-day POM (odds ratio 1.89, 95% confidence interval 1.3-2.75, p = 0.001). CONCLUSION: TMIE is associated with a lower 90-day POM rate compared with OE and offers reduced rates of pulmonary complications compared with OE and HMIE. After previous adoption of the HMIE technique, TMIE can be safely implemented in high-volume centers nationwide.

Increasing burden of viral bronchiolitis in the pediatric intensive care unit; an observational study.

PURPOSE: Viral bronchiolitis is a major cause of pediatric intensive care unit (PICU) admission. Insight in the trends of bronchiolitis-associated PICU admissions is limited, but imperative for future PICU resource and capacity planning. MATERIALS AND METHODS: We retrospectively studied trends in PICU admissions for bronchiolitis in six European sites, including three full national registries, between 2000 and 2019 and calculated population-based estimates per 100,000 children where appropriate. Information concerning risk factors for severe disease and use of invasive mechanical ventilation was also collected when available. RESULTS: In total, there were 15,606 PICU admissions for bronchiolitis. We observed an increase in the annual number, rate and estimates per 100,000 children of PICU admissions for bronchiolitis at all sites over the last two decades, while the proportion of patients at high risk for severe disease remained relatively stable. CONCLUSIONS: The international increased burden of bronchiolitis for the PICU is concerning, and warrants further international attention and investigation.

Analysis of Hip Fractures in France During the First COVID-19 Lockdown in Spring 2020.

Importance: The COVID-19 pandemic has posed a number of unprecedented challenges to the health care system in France, where hip fractures in the elderly population are a major public health concern. Objective: To explore the association of the first nationwide COVID-19 lockdown in France with the absolute number of hip fractures among patients 50 years or older. Design, Setting, and Participants: This retrospective cohort study used data from the French national hospitals database to identify patients 50 years or older who were hospitalized for hip fracture in France from January to July 2019 and January to July 2020. Exposures: The first nationwide COVID-19 lockdown in France from March 16 to May 10, 2020. Main Outcomes and Measures: The main outcome was the number of hospitalizations for hip fracture from January to July 2020 (study period) compared with the number of hospitalizations for hip fracture during the same period in 2019 (control period). Hospitalization rate ratios (HRRs) comparing the study period with the control period were calculated for 3 intervals (before lockdown [January 1 to March 15], during lockdown [March 16 to May 10], and after lockdown [May 11 to July 31]) and were stratified by gender, age and hospital type. Results: The study included 46 393 patients hospitalized for hip fracture during January to July 2019 (34 589 [74.4%] women; mean [SD] age, 82.8 [10.5] years) and 44 767 patients hospitalized for hip fracture from January to July 2020 (33 160 [74.1%] women; mean [SD] age, 82.9 [10.5] years). During the lockdown in 2020, 10 429 patients (23.30%) were hospitalized for hip fracture compared with 11 782 patients (25.40%) during the same period in 2019 (HRR, 0.89; 95% CI, 0.86-0.91; P < .001). The lockdown period was associated with a decrease in the number of hip fractures of 11% among women (from 8756 in 2019 to 7788 in 2020) and 13% among men (from 3026 in 2019 to 2641 in 2020). When the absolute number of hip fractures was stratified by age group, the lockdown period was associated with a decrease in the number of hip fractures in all age groups except in patients older than 89 years (HRR, 0.97; 95% CI, 0.92-1.01; P = .17). In the group of patients aged 80 to 89 years, the number of hip fractures decreased from 4925 to 4370 (HRR, 0.89; 95% CI, 0.85-0.92; P < .001). During the lockdown, hospitalizations decreased by 33% (HRR, 0.67; 95% CI, 0.63-0.71; P < .001) in public university hospitals and by 24% (HRR, 0.76; 95% CI, 0.73-0.79; P < .001) in public general hospitals but increased by 46% (HRR, 1.46; 95% CI,1.38-1.54; P < .001) in private for-profit hospitals. Conclusions and Relevance: In this cohort study, hospitalizations for hip fractures in France decreased by 11% during the first nationwide COVID-19 lockdown. Further studies are needed to investigate the long-lasting consequences of the COVID-19 pandemic on the incidence of osteoporotic fractures.

Risk factors of mortality among patients hospitalised with COVID-19 in a critical care or hospital care unit: analysis of the French national medicoadministrative database.

OBJECTIVE: To explore mortality risk factors for patients hospitalised with COVID-19 in a critical care unit (CCU) or a hospital care unit (HCU). DESIGN: Retrospective cohort analysis using the French national (Programme de médicalisation des systèmes d'information) database. SETTING: Any public or private hospital in France. PARTICIPANTS: 98 366 patients admitted with COVID-19 for more than 1 day during the first semester of 2020 were included. The underlying conditions were retrieved for all contiguous stays. MAIN OUTCOME MEASURES: In-hospital mortality and associated risk factors were assessed using frailty Cox models. RESULTS: Among the 98 366 patients included, 25 765 (26%) were admitted to a CCU. The median age was 66 (IQR: 55-76) years in CCUs and 74 (IQR: 57-85) years in HCUs. Age was the main risk factor of death in both CCUs and HCUs, with adjusted HRs (aHRs) in CCUs increasing from 1.60 (95% CI 1.35 to 1.88) for 46 to 65 years to 8.17 (95% CI 6.86 to 9.72) for ≥85 years. In HCUs, the aHR associated with age was more than two times higher. The gender was not significantly associated with death, aHR 1.03 (95% CI 0.98 to 1.09, p=0.2693) in CCUs. Most of the underlying chronic conditions were risk factors for death, including malignant neoplasm (CCU: 1.34 (95% CI 1.25 to 1.43); HCU: 1.41 (95% CI 1.35 to 1.47)), cirrhosis without transplant (1.41 (95% CI 1.22 to 1.64); 1.27 (95% CI 1.12 to 1.45)) and dementia (1.30 (95% CI 1.16 to 1.46); 1.07 (95% CI 1.03 to 1.12)). CONCLUSION: This analysis confirms the role of age as the major risk factor of death in patients with COVID-19 irrespective to admission to critical care and therefore supports the current vaccination policies targeting older individuals.

Partial Versus Total Thyroidectomy: What Influences Most Surgeons' Decision? Analysis of a Nationwide Cohort of 375,810 Patients Over 10 Years.

National and international guidelines about thyroid surgery seem to be moving more and more towards less radical surgical procedures but everyday practice does not seem to always align with them. We describe for the first time the role of non-surgical parameters in the surgeon's choice for thyroid surgery. OBJECTIVE: The ain of this study was to describe thyroid surgery and to identify the factors leading to either a total or a partial thyroidectomy regardless of the severity of the thyroid disease. SUMMARY BACKGROUND DATA: National and international guidelines about thyroid surgery seem to be moving more and more toward less radical surgical procedures but everyday practice does not seem to always align with them. METHODS: We based this nationwide retrospective cohort study on a national database that compiles discharge abstracts for every admission for thyroidectomy to French acute healthcare facilities (PMSI database 2010 to 2019). RESULTS: In this study, 375,810 patients (male: 23%; age = 53 ±â€Š15 years) had a thyroidectomy (partial: 28%) for cancer (17%), hyperthyroidism (16%), nonfunctioning goiter (64%), or other (3%). We noticed a global trend toward more partial thyroidectomy (P < 0.001) with a significant increase in the proportion of lobectomy in the post-ATA recommendations' period (P < 0.001) as well as in the "French Levothyrox crisis" period, in which we saw an unexpected rise of adverse events notifications associated with the marketing of a new formula of Levothyrox (P < 0.001) amid widespread media coverage. In a multivariate analysis, we also identified that complete resection was more frequently performed in centers with a caseload >40/year [P < 0.001, odds ratio (OR) = 1.48], for obese patients (body mass index >30 kg/m2; P < 0.001, OR = 1.42), and according to the indication of surgery (OR benign = 1, OR cancer = 2.25, OR hyperthyroidism = 4.13). CONCLUSION: We describe for the first time the role of non-surgical parameters in the surgeon's choice for thyroid surgery.

Automated Generation of Individual and Population Clinical Pathways with the OMOP Common Data Model.

INTRODUCTION: Clinical pathways represents the sequence of interventions from which the patients benefit during their encounters with health care structures. There are several complex issues which make it difficult to represent these pathways (e.g. high numbers of patients, heterogeneity of variables). METHODS: We developed a tool to automate the representation of clinical pathways, from an individual and population points of view, and based on the OMOP CDM. The tool implemented the Sankey diagram in three stages: (i) data extraction, (ii) generation of individual sequence of steps and (iii) aggregation of sequence to obtain the population-level diagram. We tested the tool with three surgery procedures: the total hip replacement, the coronary bypass and the transcatheter aortic valve implantation. RESULTS: The tool provided different ways of visualizing pathways depending on the question asked: a pathway before a surgery, the pathway of deceased patients or the complete pathway with different steps of interest. DISCUSSION: We proposed a tool automating the representation of the clinical pathways, and reducing complexity of visualization. Representations are detailed from an individual and population points of view. It has been tested with three surgical procedures. The tool functionalities will be extended to cover a greater number of use cases.

National early warning score to predict intensive care unit transfer and mortality in COVID-19 in a French cohort.

BACKGROUND: No risk stratification tool has been validated in hospitalised patients with coronavirus disease 2019 (COVID-19), despite a high rate of intensive care requirement and in-hospital mortality. We aimed to determine whether the National Early Warning Score (NEWS) at admission can accurately predict in-hospital mortality and ICU transfer. METHODS: This was a retrospective cohort study from January 24 to April 16, 2020, at Lille University Hospital. All consecutive adult patients with laboratory-confirmed COVID-19 who were initially admitted to non-ICU wards were included. The primary outcome was a composite criterion consisting of ICU transfer or in-hospital mortality. We evaluated the prognostic performance of NEWS by calculating the area under (AUC) the receiver operating characteristic curve, the optimal threshold value of NEWS, and its association with the primary outcome. RESULTS: Of the 202 COVID-19 patients, the median age was 65 (interquartile range 52-78), 38.6% were women and 136 had at least one comorbidity. The median NEWS was 4 (2-6). A total of 65 patients were transferred to the ICU or died in the hospital. Compared with patients with favourable outcome, these patients were significantly older, had more comorbidities and higher NEWS. The AUC for NEWS was 0.68 (0.60-0.77) and the best cutoff value was 6. Adjusted odds ratio for NEWS ≥ 6 as an independent predictor was 3.78 (1.94-7.09). CONCLUSIONS: In hospitalised COVID-19 patients, NEWS was an independent predictor of ICU transfer and in-hospital death. In daily practice, NEWS ≥ 6 at admission may help to identify patients who are at risk to deteriorate.